Routine inspection·July 9, 2025

On July 09, 2025, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the caregiver, Josephine Caliboso, and disclosed the purpose of the inspection. The caregiver informed the LPA that the facility had four (4) residents in care and (2) staff members present at the time. The Licensee, Melburga Senot joined shortly after. At 9:15 AM, the LPA initiated a walk-through of the facility, accompanied by the caregiver. LPA inspected the kitchen and there was no food preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet containing knives and sharp objects, and a locked cabinet under the sink with detergents and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted. LPA inspected the dining area adjacent to the kitchen. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. Two (2) residents were observed to eat breakfast on the dining table. LPA inspected the living room and observed it clean, with all furniture in good repair. There were sofa sets, reclining chairs, tables, and a television in the living room. There were three (3) bedrooms and (2) bathrooms designated for residents' use. All resident rooms were shared occupancy. Continued on LIC809-C LPA inspected all resident rooms and found them clean, well-lit, and equipped with the required furniture. LPA inspected two (2) shared bathrooms and found them sanitary, and in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower chair, and non-slip flooring/mats. At 9:42 AM, the hot water temperature at the sink faucet in both the bathrooms was measured between that range of 126.1°F to 126.7°F. At 09:58 AM, LPA inspected the garage and observed it cluttered with the incontinence supplies, furniture, food supplies, wheelchairs, mattresses, and suitcases. LPA observed a washer and a dryer in the garage. LPA inspected one (1) storage closet in the hallway and observed that they contained clean linens, blankets, and towels for residents’ use. LPA inspected the fire extinguisher mounted on the wall in the living room and found it fully charged, with the last service tag dated 01/31/2025. The caregiver tested the smoke and carbon monoxide detector located in living room in the LPA's presence, and it was found to be functional. Additional smoke and carbon monoxide detectors were observed in all bedrooms and common areas of the facility during the visit. LPA toured the backyard and found ramps and passageways clear of obstructions, with no blocking or tripping hazards. No bodies of water were noted. LPA reviewed two (2) staff personnel records and four (4) resident records. LPA observed that four (4) of four (4) residents had an Admission Agreement, Physician's Report, Appraisal/Needs and Services Plan, and CSDMR. LPA observed that two (2) of two (2) staff members had current First Aid certificates, LIC 508 Criminal Record Statements, and LIC 503 Health Screenings, and confirmed that two (2) of two (2) staff members were associated with the facility. LPA observed a locked centrally stored medication cabinet in the kitchen. Medications were organized separately for each resident. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records were reviewed. At 10:50 AM, LPA observed that 1 of 4 residents’ R1’s one prescription medication name, prescription number, and date filled were not entered in the Centrally Stored Medication Records (CSMR). LPA inspected the first aid kit and found it fully stocked. Continued on LIC809-C Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster (Fire and Earthquake) Drills were conducted quarterly, with the most recent drill completed on 07/01/2025. The following updated forms are requested to be submitted to CCLD by 07/16/2025: LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility Certificate of Liability Insurance Administrator Certificate(s) Control of Property (Grant Deed) The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, and Plans of Correction were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with the Licensee, Melburga Senot, whose signature on this form confirms receipt of these documents.