Routine inspection·September 23, 2025

On 09/23/2025, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with care staff Miranda Agaphia and explained the purpose of the visit. LPA Lee informed care staff Agaphia to let the facility designated administrator (FDA) Mary Jane Apuya to informed that CCLD was present in the facility. Care staff Agaphia assisted with today’s visit. Administrator certificate # is 7001464740 and will expires on 11/01/2026. The current census is 3 with 2 facility staff. This facility is a single story building licensed to serve six (6) ambulatory and non-ambulatory residents. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry 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 116.4 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. CONTINUED LIC 809-C The fire extinguisher is in the dining room and was last serviced on 02/26/2025. The last fire drill was conducted on 09/02/2025. LPA Lee observed the facility has a has a public telephone in the common area desk and the facility has the required posters posted. The facility thermostat was observed at 77 degrees Fahrenheit. LPA Lee observed toxins located in one of the hallway closet and kept locked and inaccessible to residents. LPA Lee observed sharp knives kept locked in the kitchen cabinet and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 3 out of 3 resident medications on hand the Centrally Store Medication Destruction Record and it was complete. The first aid kit was checked and contained the required components. LPA Lee requested resident and staff files for review. LPA Lee reviewed 3 out of 3 resident files and they were complete. LPA Lee reviewed 2 staff files, and it was complete. The following documents will be email to LPA by 10/03/2025 at the 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 (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 care staff Agaphia and a copy of these LIC 809 reports were provided to the facility.