Routine inspection·July 15, 2025

On 07/15/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with administrator Editha Muncada and explained the purpose of today's visit. There are 7 residents and 2 staff present, one being the administrator. This is a single level facility. All residents are approved to be non-amblatory and 3 hospice residents per waiver on file. There are 3 residents on hospice at this time. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen in a drawer adjacent to the facility stove. Medications are observed to be locked in a kitchen cabinet. Perishable and non-perishable food items are observed as in place. Cleaning supplies are observed to be locked beneath kitchen sink. First aid kit is observed as complete with required items. LPA observed that there are three fire extinguishers in place last inspected 08/15/2024, smoke detectors, carbon monoxide detectors are observed in place through out the facility, facility is equipped with full fire sprinklers through out, and central heating system including fans for facility use. PPE supplies and linen supplies are in place. Laundry area is also observed as fully operational in an exterior shed. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Facility does not have a record for conducting an emergency which can pose a potential health and safety. Water temperature was measured at 120F in a common bathroom in the hallway connecting to resident rooms. There is one bathroom that is out of order in the living room area that is used for storage but there are an additional two full bathrooms for resident use. Continued on next page... Page 2 LPA observed resident rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Client linen supplies are observed as in place. Facility disaster drill conducted on 04/03/2025. LPA reviewed 6 of 7 resident files due to computer issues. 3 staff files are reviewed as current Administrator certificate is observed as current expiring on 08/13/2026 The following updated forms are requested to be submitted to CCLD by 07/22/2025 : • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule Technical violation are issued and attached on the following LIC9102 page. Report is reviewed with administrator Editha Muncada.