Routine inspection·July 24, 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 Rina Canonizado. LPA spoke with House Manager Lauren DeLancey via telephone during the visit. The facility is licensed for a maximum capacity of 6 residents, 2 of which may be non-ambulatory in bedroom #1. The facility has a waiver for 6 hospice residents. During today’s visit, the facility had a census of 5 residents, all of which were non-ambulatory and receiving hospice services. 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 rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. Upon attempting to enter the facility, LPA observed a locked gate with a keypad preventing access to the front door. Staff Canonizado exited the facility and entered a code into the keypad which unlocked the gate and allowed LPA entrance into the facility. The facility's approved fire clearance granted on 3/15/2024 did not note any use of locked perimeter or delayed egress. LPA tested the gate during the facility tour and observed that the gate was locked from both sides, preventing unobstructed egress in case of emergency. Additionally, a tour of the facility's backyard revealed that the side gate was locked at the time of the inspection and had a doorknob with a locking mechanism, further preventing egress is case of emergency. The facility was found to be clean, safe, and in good repair. The facility’s water temperature was measured at 107.2 degrees Fahrenheit at the kitchen sink and 117.0 degrees Fahrenheit in a common bathroom. The facility’s internal temperature was measured at 73 degrees Fahrenheit. Continued on LIC809-C page... LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Rina Canonizado, no firearms or weapons are stored on the premises. 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. According to staff and LPA observation, the facility refrigerator located in the kitchen was non-operational and was empty of food supplies. The facility has a refrigerator and freezer located in the garage that was operational and contained the perishable food supply. The garage refrigerator and freezer temperatures were kept within regulatory levels. 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. Review of resident records revealed that 5 of 5 residents were deemed non-ambulatory due to either the diagnosis of a major neuro-cognitive disease or the use of ambulation devices such as walkers and wheelchairs. Additionally, review of hospice binders revealed that 3 of 5 residents (Residents 1, 2, and 4) did not have hospice care plans. [Staff Canonizado was provided with an LIC811 Confidential Names list to identify residents.] Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance, and a health screening. LPA was away from the facility for approximately one hour between 11:10am and 12:10pm. The following deficiencies were cited for locked perimeter gates, over capacity for non-ambulatory residents, and missing hospice care plans and noted on the attached LIC809-D pages. Additionally, two civil penalties in the amount of $500 each, totalling $1,000 were assessed for locked perimeter and non-ambulatory capacity and noted on the attached LIC421IM forms. Additionally, LIC9102TV Technical Violations regarding staff association and shaded outdoor spaces were provided. An exit interview was conducted with House Manager Lauren DeLancey via telephone and Caregiver Rina Canonizado, whose signature below confirms receipt of a copy of this report, the LIC421IMs, the LIC811, the LIC9102TV forms, and the Licensee Appeal Rights (LIC9058 3/22).