Post-licensing visit·July 28, 2025

On 7/28/2025 at 1:09 AM, Licensing Program Analyst (LPA) Cynthia Tamayo arrived at the facility for an announced to conduct a Post-licensing inspection. LPA was greeted by staff member, Josaia Sigavata and explained the purpose of the visit. Facility Designated Administrator (FDA), Solate (Charlotte) Lewis was contacted by staff. LPA Cynthia Tamayo met with staff Josaia Sigavata and explained the purpose of the visit. Staff member Josaia Sigavata is associated to the facility and has a currect CPR certification. Tevita Kaloulasulasu holds an active administrator certificate # 6072342740and is valid until 10/24/2026. Current census was 5. This facility a Residential Care Home for the Elderly (RCFE) licensed to serve age range 60 and over, approved for 6 non-ambulatory. The facility has a waiver granted for hospice care for two (2). There is one staff bedroom that is inaccessible to residents. There are currently no residents on hospice at this time. LPA reviewed 5 out of 5 resident files and 3 staff files. Resident and staff files were complete. Hot water temperatures were taken to ensure it was in the regulation of 105-120 degrees and it measured at111.7 * F. Carbon monoxide and smoke alarms were present and were in working condition. A sample menu was observed in the kitchen area. Common areas for resident use were toured. Furniture and furnishings were observed to be present and in compliance. The facility temperature was at 71 degrees Fahrenheit which is within the required range of 68-85 Fahrenheit. Continued on 809-C Grab bars and non-skid mats were present and functional. Resident bedrooms were toured. Furniture and furnishing were observed to be present and in good condition. LPA observed an operating telephone (916-509-9693) located in the living room. A linen closet was located in the hallway and had sufficient number of linens at this time. The kitchen area was toured. Facility freezer and refrigerator showed to be functional. LPA Tamayo observed that there were not 7 days of nonperishable food in the pantry. LPA Tamayo observed the centrally stored medications area to be locked and inaccessible to residents. The fire extinguisher(s) and first aid kits were up to date. Smoke and carbon monoxide detector(s) were in good repair. An activity Calendar was observed in the common areas. The pool is gated and inaccessible to residents. The facility has a cleaning maintenance scheduled for the pool. The following documents will be email to LPA by 8/4/25 end of day 5:00 PM: 1) LIC 308 current Designation of Administrative Responsibility 2) LIC 9020 current Resident Roster 3) Daily/weekly menu with special diet modification for each resident for July- August 2025 4) Activity Calendar for July – August 2025 5) Dementia Training verifications for all staff 6)LIC 500 Personnel Report for July - August 2025 As a result of this post licensing visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted with Josaia Sigavata and a copy of these LIC 809 reports were provided to the facility.