Routine inspection·May 1, 2025

At approximately 9:30 AM, Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to conduct a required 1-year annual inspection and was greeted by Caregiver Jonas Pecson. Housemanager Glenda Labata was called and gave verbal consent for Caregiver to sign and receive this report. Facility is a Residential Care Facility for the Elderly (RCFE) with three (3) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for two (2), with zero (0) Hospice residents currently in care, and is approved for all non-ambulatory residents. At approximately 9:50 AM, LPA initiated a tour of the facility with Caregiver and observed the following: Facility is a one (1) story home, was a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were purchased 6/24. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Water temperature measured 105.2 degrees F, which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food, as well as an emergency water supply. Food was found to be stored in a safe manner with open items covered. There is a shaded seating area in the backyard with outdoor space for activities. LPA observed two (2) locked sheds in the backyard which LPA inspected and observed the contents of one (1) to consist of tools and the contents of the other to be home maintenance supplies Facility has an internet access device designated for resident use and internet service available. Facility telephone was observed operational during inspection. Facility plays bingo and cards, conducts supervised gardening, has movie nights, and takes residents into the community. LPA observed that the garage has been converted into a three (3) room staff resting area which is not reflected on LIC999-Facility Sketch. LPA informed Caregiver that Licensee is to submit a new LIC999 marking the additional rooms and facility will require a new fire inspection. Continued 809C... Continued from 809... Facility conducts monthly disaster drills, and the most recent drill was conducted 3/25. LPA observed facility's infection control plan and emergency disaster plan which was last updated 8/2024. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights. At approximately 10:50 AM LPA conducted a review of three (3) resident records. All required documentation present. At approximately 11:10 AM LPA conducted review of four (4) staff records. All required documentation present. At approximately 11:50 AM LPA and Caregiver conducted a spot check of medication and medication records. Medication is centrally stored and locked. Ruby Anne Alinio Administrator Certificate 6072575740 expires 10/8/2026. All fees are current as of this time. Updated copies of the following documents shall be submitted to CCL within 30 days of this visit : Liability Insurance LIC999 - Facility Sketch LIC500 - Personnel Report LIC308 - Designation of Responsibility LIC400 - Affidavit Regarding Client Cash Resources LIC610D - Emergency Disaster Plan No deficiencies cited. Exit interview conducted with Caregiver, whose signature on form confirms receipt.