Routine inspection·April 8, 2025

Licensing Program Analyst (LPA) Rankin arrived at 9:25 am to conduct a 1-year annual visit to the facility above. LPA met Administrator Alan Sepulveda and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility is a 6 bedroom and 4 ½ bathroom, with 1 bedroom and ½ bathroom dedicated to staff. The facility is occupying 6 residents and employs 5 staff of which one is the Administrator, and one is a live in staff. The facility is clean, safe and sanitary, areas that need additional upkeep were noted to the administrator. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. Carbon Monoxide was tested and working properly and fire alarm was tested and working. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The showers have non-skid mats and/or flooring. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are stored under kitchen sink and in the garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with furniture and plenty of shade. The backyard has a locked shed to store extra furniture and items. Operational Requirements: The facility has a current plan of operation on file. The Facility is operating in compliance with the granted fire clearance based on the facility sketch. The facility has current liability insurance and expires on 03/20/2026. The facility is approved for a capacity of 6 non-Ambulatory and approved for hospice waiver of 6. Continued 809-C Staffing, Personnel Records & Training: Staff records are kept confidential. LPA reviewed 4 staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/ exemptions. Administrator Certificate expires on 7/13/26. All files were kept up to date with all requirements being met. LPA reviewed staff training records for Annual Training Requirements of 20 plus hours. Administrator is in the process of completing April’s training. Initial training was kept on file. Resident Records & Incident Reports: The facility keeps separate files on each resident confidential. Five files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. Incidental Medical & Dental : The facility has a medication cabinet in the family room that is kept locked. Facility provides or assist in providing transportation to medical and dental appointments when needed. The medications records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA reviewed a sampling of residents’ medications, no medications labels were altered, no expired medications, and medications were stored in original containers. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, and insects. Disaster Preparedness : The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged, and an inspector is coming out on 04/14/25 for annual review which was last done on 04/18/24. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility does not have delayed egress. The facility does have 1 resident with PRN oxygen available if needed. The facility does have 5 hospice residents in care. The facility has 1 resident currently on Home Health services. The backyard is completely fenced. Exit interview conducted and copy of report printed for Administrator.