Routine inspection·August 18, 2025

On 08/18/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with administrator Patricia De Guzman and explained the purpose of today's inspection. There are currently 11 residents in the facility and 4 staff persons working on this day. This is a single level facility, licensed for residents age range of 60 years and over all of which may be non-ambulatory with a hospice waiver for 5 residents and a waiver for 4 bedridden. There are 4 hospice residents at this time. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. The facility itself is the lower level of the home. There is locked access to the facility from the upper floor. The upper floor is privately owned by the landlord of the entire physical plant. The facility garage is on the lower level. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in in kitchen drawer adjacent to the stove/range. Medications are locked in a cabinet located in the dining room area. Perishable and non-perishable food items are observed as in place. There is an additional refrigerator for resident food supplies located in the garage along with incontinence supplies and PPE. First aid kit is observed as complete with required items and stored in the medicine cabinet. LPA observed that there are three fire extinguishers in place inspected on 01/07/2025, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central HVAC. Fire pull station is located at the front door of the facility. Facility is fully equipped with fire sprinklers. Laundry area is also observed as fully operational, and locked in the garage area of the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 05/10/2025. Water temperature is measured at 105F in the common bathroom located at the end of the hall. Cleaning supplies are observed to be locked an not accessible to residents A fire panel is present at the end of the hall with an inspection date of 07/05/2023. Linens are observed as in place in a hallway closet. Continued on next page... Page 2 LPA observed resident rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. All resident rooms contain a half bathroom. There are two staff rooms as well which are labeled. There is one common full bathroom located in the hallway. Shower floor does have non-skid mats present for use. During today's inspection LPA reviewed 5 resident files which are current and 5 staff files which are current. Training hours are on file as current for staff. Medications are inspected and are accurate to what is listed on centrally stored medication and destruction record. Administrator certificate is current expiring on 11/27/2025. The following updated forms are requested to be submitted to CCLD by 08/25/2025 : • Copy of updated administrator certificate • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule No citations issued on this day. Report is reviewed with administrator Patricia De Guzman.