Routine inspection·March 19, 2025

Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Hernandez met with Administrators Ernesto Custodio and Athina Custodio. The capacity is (6) current census is (5). The facility sis a four (4) bedroom, two (2) bathroom home with a kitchen/dining area, living room and attached garage. The facility is Residential Care Facility for the Elderly (RCFE). LPA Hernandez was accompanied by Administrators Ernesto Custodio and Athina Custodio to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 70 degrees. LPA Hernandez inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA tested water temperature to be at 111 degrees Fahrenheit. LPA Hernandez observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. Care & Supervision: The facility has sufficient number of staff to provide care and supervision to the residents in care. **Continuation on LIC809-C** Record Review: LPA Hernandez reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Hernandez observed resident files reviewed were complete. LPA observed three (3) residents medications. LPA observed prescription label altered by no label being present for medication for Client #3 (C3). Deficiency will be issued. LPA observed for all (3) residents medications were not stored in a original container but moved to a different container. Deficiency will be issued. Additionally, LPA observed medication for all (3) residents to not be documented and signed in Medication Administration Record (MAR). Deficiency will be issued. Also, LPA advised Administrators when PRN medication is being taken it shall be documented with staff signature, resident's response and date and time taken. Technical Violation was given. LPA Hernandez reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) test result. No issues were observed Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) (LIC809D) and (LIC9102) was discussed and provided to Administrator Ernesto Custodio and Athina Custodio along with copy of Appeal Rights.