Routine inspection·January 26, 2026

On 01/26/2026, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with Administrator Carmen Navarro and explained the purpose of the visit. The current census is 5 with 2 facility staff. This facility is a single story building licensed to served six (6) non-ambulatory clients. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room, garage, staff room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 115.9 degrees Fahrenheit in client bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. The smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 12/10/2025. The last fire drill was conducted on 12/15/2025. LPA Lee observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. Facility thermostat was observed at 73 degrees Fahrenheit, which is within the required regulation of 68 to 85 degrees Fahrenheit. LPA Lee observed toxins located in the kitchen sink and kept locked and inaccessible to client. LPA Lee observed sharp knives kept locked in the kitchen cabinet and inaccessible to client. LPA Lee checked medication storage and found medication to be locked away and inaccessible to client. The first aid kit was checked and contained the required components. CONTINUED LIC 809-C LPA Lee audited medications for 2 out of 5 clients by comparing the medications on hand with their Medication Administration Records (MARs) and it was complete. LPA Lee audited the Personal and Incidental (PNI) funds for all five clients, and the records were found to be incomplete. Four of the five clients’ PNI balances were over by amounts ranging from $0.01 to $3.50, and one client’s PNI balance was under $0.75. It was learned that the administrator did not have exact change available. During the audit of a client’s PNI, LPA Lee observed the administrator holding additional money being added to client’s money. When questioned about who’s money it was, the administrator was stated that the money was her personal funds, taken from her handbag. LPA Lee informed the administrator that client funds cannot be commingled with the clients PNI.LPA Lee reviewed 5 out of 5 client files, and they were complete. LPA Lee reviewed 2 staff files, and it was also complete. LPAs reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following documents will be emailed to LPA Lee by 01/30/2026 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) LIC 500 Current Personnel Report As a result of this annual visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted with Administrator Navarro a copy of these LIC 809 reports was provided to the facility.