Routine inspection·April 1, 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 Carlito Caoili. The facility is licensed for a maximum capacity of 6 residents, 4 ambulatory and 2 non-ambulatory in bedroom #4. As of 10/8/2024, the facility has a pending fire clearance request to increase the facility's capacity to 6 non-ambulatory residents. The facility has a waiver for 6 hospice residents. During today’s visit, the facility had a census of 6 non-ambulatory residents, 5 of which were receiving hospice services. The Administrator for the facility is Laurice 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 initially measured at 130.6 degrees Fahrenheit in a private resident bathroom. LPA observed Caregiver Caoili turn down the hot water heater during the visit. LPA remeasured the hot water before the end of the visit and the hot water was measured at 118.8 degrees F in the private resident bathroom, 118.2 degrees F in the common bathroom, and 113.5 degrees F in the kitchen sink. The facility’s internal temperature was measured at 76 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Caregiver Sylvia Linga, no firearms or weapons are stored on the premises. Continued on LIC809-C page… LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. 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 and facility freezer temperatures met regulatory requirements. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance 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 a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns. LPA was away from the facility for approximately one hour between 12:10pm and 1:10pm. The following deficiency was cited for hot water temperature and noted on the attached LIC809-D page. Caregiver Caoili was able to clear the deficiency during the visit, and LPA provided Caregiver Caoili with a Letter of Deficiencies Cleared. An exit interview was conducted with Caregiver Sylvia Linga, whose signature below confirms receipt of a copy of this report, the Letter of Deficiencies Cleared, and the Licensee Appeal Rights (LIC9058 3/22).