Routine inspection·December 1, 2025

On 12/01/2025 at approximately 1PM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Residential Care Facility for The Elderly (RCFE). LPA was greeted by Staff Member, Esperenzo Konakawa. Administrator, Romeo Cabe arrived shortly after. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents. Facility has an approved hospice waiver for 5 individuals. Upon arrival, LPA was informed that there were 6 residents in care and 2 staff members on-site. Facility is a 1 story building with 6 Resident bedrooms, 2 bathrooms, and common spaces. At approximately 1:30PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 02PM, LPA and Administrator toured the building 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 does the grocery shopping once a week. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Staff were in the process of putting up Christmas decoration at the time of this inspection. Toxins are stored in a locked housekeeping closet in the laundry room and under the kitchen sink. Water temperature measured 110.6 degrees F and 112.4 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire Extinguishers found to be last charged on 26/08/2025 at the time of visit. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in a closet next to the living room. Continued on LIC809-C... Continued from LIC809... LPA reviewed 3 resident records and found all residents have current care plans, signed admission agreements, and physician's report on file. 3 out of 3 residents did not have documentation of signed personal rights: Form LIC613 and Emergency information: Form LIC601 (Technical advice given). Medication records are thorough and contained physician's orders for each resident. LPA reviewed 3 staff records. 3 of 3 records did contain documentation of completed training records as required. Evidence of current first aid and CPR training were current. LPA was presented with proof of current CPR & 1 st Aid certification. Administrator Certificate is for Romeo Cabe #7008153740 expires 06/04/2027. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 12/31/2024 (Technical Violation Given). Administrator agrees to conduct disaster drill quarterly and will submit the proof of documentation to CCL by 12/15/2025 Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 12/15/2025: LIC 308 Designation Facility Responsibilities LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (If Changed) LIC 9020 Register of Facility Client’s/Resident’s Copy/Proof 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 Administrator. Signature on form confirms receipt of documents.