Routine inspection·April 7, 2025

At approximately 09:25AM Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct an Annual Required 1 Year inspection and met with Administrator, Mary Jane Mendoza. Upon arrival, LPA was informed that, there are currently 5 residents in care. This facility is licensed for 6 non-ambulatory residents, with hospice waiver approved for 2 of the residents and none of the residents are approved for bedridden. At approximately 10:05AM LPA toured the building and grounds which was found to be clean at a comfortable temperature and in good repair. All walkways and exits were observed to be unobstructed. Client rooms were furnished per regulation. Water temperature accessible to clients in care measured 107.2 degrees F which are within the required regulation range of 105 to 120 degrees F. Extra hygiene products and linens were available. Cleaning supplies are locked and not accessible to clients. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Fire extinguishers were last serviced 05/11/2024. Smoke/Carbon Monoxide detectors were operational. Most recent fire/disaster drill was conducted January 11, 2025 At approximately 11:15PM, LPA reviewed 5 resident records. Administrator stated 2 out of 5, residents R1 and R2 waiting the Appraisal & Needs Service Plan to be signed by the resident representative for R1 and R2 (Technical Advice Given). Every resident has I.D. and Emergency Information document on file. All clients have medical assessments are updated. Continued on LIC809-C… Continued from LIC809… At approximately 11:35AM, LPA reviewed 3 staff records and staff files were containing all required documents per regulation. LPA was presented with proof of current CPR, & 1 st Aid certification for all staff. Administrator Certificate for Administrator Mary Jane Mendoza current and expires on 01/08/2027. Certification No: 7006815740(RCFE) Medications and medication records were reviewed. Medication records contained physician's orders for each resident. Medications were centrally stored and locked in medication file cabinet. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on January 11, , 2025. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Resident’s Copy of Updated Certificate of Liability Insurance No Deficiencies Cited during Visit. Exit interview conducted. Copy of report discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents