Routine inspection·July 2, 2025

Licensing Program Analyst (LPA) Cynthia Tamayo arrived at the facility unannounced for a required one-year visit. LPA arrived at 1:22 PM and met with facility Administrator Glenda Molinyawe (S2). Entrance interview conducted. Administrator Certificate # for Glenda Molinyawe is 6052178740. The facility is approved for up to 6 residents age 60 and over of which 5 may be non ambulatory and one bedridden with hospice waiver for 2. Beginning at 1:22PM, a tour of the physical plant was conducted with the Licensee to ensure residents’ health and safety and the facility is in compliance with Title 22 regulations. The following was observed: KITCHEN: Appliances and fixtures were clean and functional. The facility had ample supply of perishable and non-perishable food. Meals are prepared by the Staff. Refrigerator temperature was at 45 degrees F and freezer temperature was at 0 degrees F. Knives and other sharps are locked inaccessible in a drawer. Kitchen and house cleaning supplies are stored in a locked cabinet located under the sink. COMMON AREAS: Common areas include the Living Room and Dining Room. All furniture was observed to be clean and in good condition with enough seating for six residents . There was space to accommodate both indoor and outdoor activities. LPA noted an Activity Calendar and activity storage in the Entrance Bulletin Board. One (1) fire extinguisher was observed throughout the common area and was last serviced on 09/2025. Combination smoke detectors and carbon monoxide detectors were working and operational. Continued on 809-C EXTERIOR: Exterior passageways were clean and clear of any obstructions. There is a covered patio area for client and visitor use with furniture observed to be in good condition. Clients are supervised at all times when they are outside. There is one (1) gates with a self-latching mechanism for persons to exit the backyard in emergencies. BEDROOMS: LPA inspected facility bedrooms. The facility has six(6) total resident. Bedroom #1 is shared, Bedroom #2-5 are private and bedroom #6 is designated as private staff room. All bedrooms were observed to contain furniture, bedding and linens within regulation. Extra linens are stored in the hallway cabinet. Client bedrooms had no visible hazards or inconsistencies observed. Resident 4 (R4) in bedroom #1 is bed bound and on hospice. R4 recives oxygen and there is a posted "oxygen use" and "no smoking sign". BATHROOMS: There are three (3) bathrooms: one (1) is a resident bathroom attached to bedroom #1 and two bathrooms are in the hallway of which one (1) is a shared bathroom designated for residents and the other bathroom is designated for visitors and staff. All bathrooms were observed to be clean and sanitary, and supplied with paper and hygiene products. Water temperature was tested and both measured at 114 degrees F. MEDICATION REVIEW: LPA reviewed medications at 4:00 PM which are centrally stored in a locked cabinet in the hallway. Five(5) out of six (6) clients medications were reviewed. All medications were stored and administered in compliance with regulation. RECORD REVIEW: LPA reviewed six (6) resident file records. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. Resident files reviewed contained all required documents. LPA reviewed three (3) staff records during today's visit. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All staff records reviewed were in compliance at the time of the visit. Continued on 809-C RESIDENT INTERVIEWS: LPA Tamayo interviewed three residents who were able to respond verbally and coherently (R1, R2, and R3). R4-R5 were asleep during this visit and R4 was hospitalized/not present at the facility during this visit. Of these, two were not diagnosed with any sort of cognitive impairments (R1 and R2). R3 voiced no concerns with their quality of care, and said they receive all assistance when needed. R1 voiced no concerns with quality of care, and said that other residents are cared for appropriately by staff, such as ensuring that they are bathed and that their diapers are changed regularly. R1 stated they were off their medications when they made a complaint. R2 voiced no concerns with their quality of care and said they had their basic needs met and they receive assistance with other ADLs when requested. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility's infection control plan as well as the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are within regulation. Both documents were observed to be complete and recently updated. Personal Protection Equipment (PPE) and extra emergency supplies, including emergency food and water, are stored in the garage. The following documents will be email to LPA by 7/11/25 end of day 5:00 PM: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610 Current Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) Surety Bond (7) LIC 309 Administrator Organization As a result of this annual visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted with Glenda Molinyawe, and a copy of these LIC 809 reports were provided to the facility.