Routine inspection·June 30, 2025

Licensing Program Analyst (LPA) Rebecca Borunda 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 Caregiver Leonor Gaya. LPA spoke with House Manager Lauren DeLancy via telephone during the visit. The facility is licensed for a maximum capacity of 6 residents, 5 of which may be non-ambulatory. As of 3/14/2024, the facility has a pending fire clearance request to increase the facility's capacity to 6 non-ambulatory residents, 1 of which may be bedridden. The facility also has a pending waiver request for 4 hospice residents. During today’s visit, the facility had a census of 5 non-ambulatory residents. The Administrator for the facility is Rafael Gamab and their certificate was valid and current. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident and staff rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 107.6 and 107.8 degrees Fahrenheit in common bathrooms. The facility’s internal temperature was measured at 78 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. LPA also observed locked storage for resident medications and resident and staff files. During the review of the locked medication cabinet, LPA observed the daily medications for all 5 residents were stored in a daily pill box. Interviews with staff revealed that the pill boxes only contained medications for that day. Continued on LIC809-C page… During the tour of the backyard, LPA did not observe any shaded area for resident use. Staff Gaya stated that there used to be tarps that were hung from the roof and poles that used to provide shade to the backyard but they were removed. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 44 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. According to Leonor Gaya, no firearms or weapons are stored on the premises. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, initial medical assessment, updated annual reappraisal, documents regarding safeguarding personal property and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA was away from the facility for approximately one hour between 11:50am and 12:50pm. The following two deficiencies were cited for medications not stored in their original container and not having a shaded outdoor area and are noted on the attached LIC809-D page. An exit interview was conducted with Caregiver Leonor Gaya, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).