Routine inspection·April 23, 2026

At approximately 09:45AM, Licensing Program Analyst (LPA) Ali Deniz conducted an unannounced Annual Required one (1) year inspection for this facility. LPA was greeted by Licensee/Administrator, Josephine Sana. The facility is licensed for capacity of four (4) non-ambulatory residents. The facility currently provides care for 4 residents, none of which are receiving hospice services. One of four resident was attending day program during visit. Facility is a single story building with four (4) Resident bedrooms, two and hald (2.5) bathrooms, and common spaces. At approximately 10:25AM, LPA toured the building with administrator, Josephine Sana and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Cleaning supplies and other toxins are safely stored in a locked cabinet in the laundry room and garage all of which were secured upon inspection. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in a kitchen drawer. Water was measured at faucets accessible to residents between 110.2 and 113.6 degrees F which is within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire Extinguishers found throughout the facility to be recently charged on 06/23/2025 at the time of visit. Smoke and carbon monoxide detectors are interconnected throughout the facility, tested and found to be functioning. There was enough lighting in all common areas, resident rooms, and hallways. Facility has a generator to supply power during an outage. LPA observed emergency lighting for an emergency. need Medications located in designated medication room on the hallway area and were found to be secured. LPA conducted a spot check of medications and found all medication records to be in order. Continued on LIC809-C page... Continued from LIC809 page... At approximately 11:50AM, LPA reviewed three (3) resident records and found all residents have current needs & service plans and signed admission agreements. LPA also reviewed three (3) staff records and found all records were containing required documents per regulation. LPA was presented with proof of current CPR & First-Aid certification for all the members. Administrator Certificate for Josephine Sana #7003793740 expires on 02/21/2028. LPA reviewed the facility emergency disaster plan. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 04/09/2026. LPA reviewed P&I money on and learned that four (4) out of four (4) clients P&I money are accurate and available for review at this time. 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 Designation Facility Responsibility 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 were observed in the areas inspected, No citations were issued during today’s visit. Exit interview conducted. Copy of report provided to Licensee/Administrator. Signature on form confirms receipt of documents.