Routine inspection·June 14, 2024

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Licensee (LN) Vivencio Ignacio. During the visit, LPA observed 5 residents and 2 staff. When the LPA entered the home, LPA asked for the staff members names. Staff S2 identified him/herself but his/her name did was not on the facility personnel Report Summary (LIS536). S2 stated he/she has been working at the facility for 3 weeks. LPA searched S2 on guardian and S2 is fingerprint cleared, but not associated to the facility. LPA toured the facility inside out with LN which included the Living room, kitchen, dining room, 3 restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. While touring the backyard, LPA observed some wooden planks, near bedroom #1's sliding screen door, in the backyard deck had openings. (Photographs taken.) LN stated he has been getting estimates from contractors to address the hole in the wooden planks. LN stated he was planning on fixing the damaged wooden planks by the end of next week. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 116 degrees F in resident bathrooms. Page 1 Out of 2. Fire extinguisher was serviced in July 16, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by LN, and were functional. LPA observed facility first aid kit. LPA requested to review the facility disaster drill log. LN stated the last drill conducted was on November 2023. LN stated he does not have a disaster drill log. LPA reviewed facility records for 3 staff and 3 residents. LPA conducted interviews with 2 staff and 2 residents. LPA requested to review Staff S2's training. LN stated S2 has not completed any training yet. LN stated he does not have any documentation of training for S2 either. LN stated S2 has been working at the facility since June 1st, 2024. LPA requested to review resident R1-R3's medications alongside their Centrally stored Medication Log. R1 and R2's Centrally stored Medication log is blank. Resident R3's centrally stored medication log states the latest medication start date is from April 27, 2022. (Photographs taken.) Facility ADM stated she has not updated the residents R1-R3's centrally stored medication log. ADM stated she still needs to fill out the forms and put the medications on the forms for 2024. LPA requested a copy of the following documents to be sent to the Department by June 21, 2024. 1.LIC 500, Personnel Summary 2.LIC 308, Designation of Administrative Responsibility 3.LIC400, Affidavit Regarding Client/Resident Cash Resources 4. Liability Insurance 5. LIC200, please update (i.e., new phone numbers etc), if necessary. 6. Qualifications of Administrator (Certificate) 7. Please review your facility program for updates (incorporating new laws and/or regulations) 8. Please submit copy of surety bond Deficiencies are being cited during today's visit, see LIC809-D. This report was reviewed with Licensee Vivencio Ignacio and a copy of the signed report was provided. Appeal rights were provided. END OF REPORT Page 2 Out of 2.