Routine inspection·January 6, 2026

On 01/06/2026 , Licensing Program Analysts (LPAs) Pang Lee and Cynthia Tamayo arrived at the facility to conduct an unannounced annual inspection. LPAs met with Misivono Qadroka and explained the purpose of the visit. LPAs requested that staff notify Administrator Aliti Waqalala of CCLD’s presence. The Administrator’s Certificate number is 7025683740, which expires on 06/16/2027. The facility’s current census is 10 residents , with 2 staff members present. Administrator Waqalala was not present during today’s inspection. The facility is licensed for 2 ambulatory residents in bedroom #5 only and 8 non-ambulatory residents, with an approved hospice waiver for one (1) resident . LPAs inspected the physical plant, including but not limited to the common areas, kitchen, dining area, residents’ bedrooms, residents’ bathrooms, laundry room, staff room, and outdoor courtyards, to ensure compliance with Title 22 regulations . LPAs observed the facility to be clean, free of odors, and not in good repair . Resident bedrooms were properly furnished and equipped with appropriate bedding and lighting. During today’s kitchen inspection, LPAs observed insufficient seven-day non-perishable and two-day perishable food supplies . Care staff Qadroka stated that he put in an order for food delivery yesterday and that the delivery should be delivered today around 2:05 PM to 2:35 PM. During the visit, LPAs did observe groceries being delivered to the facility from Walmart. Additionally, during a complaint control Number # 27-AS-20251231102322 on 01/05/2026, LPAs inspected the facility’s food inventory to determine whether adequate food supplies were maintained on the premises, specifically a minimum of two days of perishable food and seven days of non-perishable food, sufficient for ten residents. CONTINUED LIC 809-C LPAs discussed food supply requirements with Administrator Waqalala, who confirmed that the facility did not have sufficient perishable food supplies to prepare 60 meals for ten residents, nor sufficient non-perishable food supplies to prepare 210 meals. LPA Tamayo observed one resident request seconds; however, no additional breakfast food was available. Staff member S3 offered the residents an apple retrieved from the microwave. S3 stated that the fruit basket was placed in the microwave overnight to clear the counters and to prevent residents from eating fruit at night. S3 agreed to place the fruit basket on the kitchen counter so it would be accessible to residents. Moreover, on 01/05/2026 during a complaint control investigation, LPAs also observed the front gate to be manipulated in a way that prevents residents from easily opening the perimeter gate and exiting the facility grounds. Hot water temperature measured 112.8 degrees Fahrenheit at a resident bathroom sink, which is not within the required range of 105 to 120 degrees Fahrenheit . Smoke detectors and carbon monoxide detectors were observed to be in compliance with fire safety requirements. A fire extinguisher was observed in the kitchen and was last serviced on 01/22/2025 . LPAs reminded the facility that the fire extinguisher is due for servicing this month . The last fire drill was conducted on 10/27/2025. LPAs observed a working public telephone located in the kitchen and verified that required postings were displayed. The facility thermostat was observed at 76 degrees Fahrenheit , which is within the required range of 68 to 85 degrees Fahrenheit . LPAs observed toxic substances stored in the kitchen cabinet and kept locked and inaccessible to residents . Sharp knives were observed to be l ocked in a kitchen cabinet and inaccessible to residents . Medications were observed to be properly stored, locked, and inaccessible to residents ; however, during the first aid kit inspection LPAs observed a bottle of over-the-counter pain medication inside the first aid kit made accessible to residents since the first aid kit was not locked. Care staff Qadroka removed the medication and locked it up. The first aid kit was inspected and contained all required components. LPAs observed two broken windows in the courtyard. During a case management on 09/30/2025, LPA Tamayo provided the facility with a Technical Violation requesting that the broken windows be discarded by 10/07/2025; however, the windows have not been removed as it is a safety hazard. During the visit, LPAs observed maintenance Roseindiz taking the broken windows to be thrown away. CONTINUED LIC 809-C LPAs reviewed medications for 3 of 10 residents by comparing medications on hand with the Medication Administration Records (MARs) and observed discrepancies. It was observed that MARs were not initialed for multiple days , making it unclear whether medications were administered as prescribed or whether staff didn’t initial the MARs. Additionally, medications were observed not to be administered in accordance with the bubble pack instructions for days and times for residents . Citations will be issued on complaint control Number # 27-AS-20251231102322. LPAs reviewed 5 of 10 resident files , which were complete. LPAs also reviewed 3 staff files , which were complete. A review of staff criminal record clearances confirmed that all facility staff and required individuals are fingerprint-cleared and associated with the facility . The following documents are to be emailed to LPA Lee by 01/09/2026 by 5:00 PM : 1. LIC 308 – Designation of Administrative Responsibility 2. Copy of Administrator Certificate 3. LIC 610 – Current Emergency Disaster Plan 4. Proof of Current Liability Insurance 5. LIC 500 – Current Personnel Report LPAs reminded the facility that their annual fees are due and that LPA Lee will email Administrator Waqalala the PIN number, which can be used to pay the balance at CCLD website http://www.ccld.ca.gov/ . As a result of this annual visit, the facility is not in compliance with Title 22 regulations . Deficiencies are documented on LIC 809-D . An exit interview was conducted with Care staff Qadroka, and copies of LIC 809, LIC 809-D, and appeal rights were provided to the facility.