Routine inspection·October 3, 2024

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Helen Ibrahim . During the visit, LPA observed 6 residents and 2 staff. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 4 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. 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 75 degrees F, and hot water temperature was measured at 116 degrees F in resident bathrooms. Fire extinguisher was serviced in May 6, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on September 18, 2024. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff and 2 residents. Page 1 Out of 2. LPA requested the following documents be sent to the Department by October 10, 2024. ADM stated she will send the following documents; 1.LIC 500, Personnel Summary 2.LIC 308, Designation of Administrative Responsibility 3.LIC400, Affidavit Regarding Client/Resident Cash Resources 4. Liability Insurance 5. Qualifications of Administrator (Certificate) 6. Please submit copy of surety bond (if Applicable) 7. LIC309 Administrative Organization 8. LIC610E, Emergency Disaster Plan for Residential Care Facilities for the Elderly. 9. LIC9020, Register of Facility Clients/ Residents No deficiencies cited during today's visit. This report was reviewed with Administrator Helen Ibrahim and a copy of the signed report was provided. Page 2 Out of 2. END OF REPORT.