Routine inspection·April 15, 2024

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Licensee Teresita "Roxie" Roxas. The facility is licensed for a maximum capacity of 6 non-ambulatory residents. The facility has a waiver for 4 hospice residents. During today’s visit, the facility had a census of 5 non-ambulatory residents, 4 of which were receiving hospice services. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Teresita "Roxie" Roxas and their certificate was valid and current. During today's visit, LPA briefly toured the facility and observed residents in care, and reviewed facility records. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. During today's visit, LPA observed Person 1 (P1) present at the facility without a background clearance. [Licensee was provided with an LIC811 Confidential Names List to identify P1]. Per Licensee, P1 has been present at the facility for more than 5 calendar days. The following deficiency for uncleared individuals present at the facility is being cited per California Code of Regulations Title 22 and noted on the attached LIC809-D page. Additionally, a civil penalty for uncleared individuals is being cited for a total of $500 and noted on the attached LIC421BG form. An exit interview was conducted with Licensee "Roxie" Roxas, whose signature below confirms receipt of a copy of this report, the LIC421BG, LIC811, and the Licensee Appeal Rights (LIC9058 3/22).