Routine inspection·May 12, 2025

On May 12, 2025, at 11:20 AM, 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, Jesley Quirimit, and disclosed the purpose of the inspection. The caregiver informed the LPA that the facility had (6) residents in care and (2) staff members present at the time. At 11:34 AM, the LPA initiated a walk-through of the facility, accompanied by the caregiver. LPA inspected the kitchen and found it clean, with lunch 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 and found it clean. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. LPA inspected the family room and observed it clean, with all furniture in good repair. There were sofa sets, chairs, recliners, tables, and a television in the living room. One (1) resident was observed sitting on the recliners watching the television. There were (5) bedrooms and (3) bathrooms designated for residents' use. One (1) resident room was shared occupancy and other four (4) resident rooms were single 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) private bathrooms and one (1) common bathroom in the hallway and found them clean, 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. The hot water temperature at the sink faucet in all (3) bathrooms was measured between that range of 118.4°F to 119.2°F. LPA inspected the fire extinguisher mounted on the wall next to the dining table and found it fully charged, with the last service tag dated 09/07/2024. The caregiver tested the smoke and carbon monoxide detector located in one of the resident’s rooms 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 inspected the garage and found it clean. The access door to the garage was locked and inaccessible to residents in care. A washer, a dryer, a refrigerator and a freezer containing additional food supplies, and a staff break area were observed inside the garage. LPA toured the backyard and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. The backyard had a table, chairs, and shaded areas for resident use. No bodies of water were noted. LPA reviewed (5) staff personnel records and (5) resident records. The LPA observed that 5 of 5 residents had an Admission Agreement, Physician's Report, and CSDMR. At 1:10 PM, LPA observed that 3 of 5 residents did not have Appraisal Needs and Services Plan records. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 5 of 5 staff members were associated with the facility. At 1:42 PM, LPA observed a locked centrally stored medication cabinet in the hallway next to kitchen pantry cabinet. Medications were organized in separate bins for each resident. Centrally Stored Medication Records were reviewed and found that 2 of 5 resident’s medication prescription names, prescription numbers, and date filled were not entered correctly in the Centrally Stored Medication Records. LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted quarterly. Continued on LIC809-C The following updated forms are requested to be submitted to CCLD by 05/19/2025: LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility LIC 400: Cash Resources Affidavit Certificate of Liability Insurance Administrator Certificate(s) 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 caregiver. A copy of this report and appeal rights were discussed and provided to the caregiver, Jesley Quirimit, whose signature on this form confirms receipt of these documents.