Routine inspection·February 25, 2025

Licensing Program Analyst (LPA) Alviso, conducted a Required - 1 Yeari Inspection, on 2/25/25 at approximately 9:20am, and met with Administrator Sheila Sumabat. LPA observed two (2) caregivers, Rosie and Fely, on duty. There are currently five (5) residents in care. Facility has an approved dementia plan of operation. There is an approved hospice waiver for four (4) residents. The facility has a required infection control plan. The facility has a required emergency & disaster plan. Per review of records, fire/emergency drills are held quarterly as required: Last emergency drill conducted was a fire drill and winter storm preparedness review, held on 1/6/25 with staff.. Fire clearance is approved for six (6) non-ambulatory. Fire extinguisher is serviced and tagged as required. Facility has smoke alarms, and a carbon monoxide detector, all were working properly during the inspection. Fire extinguishers were serviced and tagged as required. LPA toured the facility with the Administrator. Hot water was checked at 112.6 degrees Fahrenheit. All exits were free and clear of obstruction. All exits had auditory alarms. All resident rooms, hallways, and common areas all had sufficient furnishings, and lighting for residents in care. All bathrooms had grab bars, and the shower bathroom had a mat for resident use. Medications were all locked and inaccessible to residents in care, and to those staff that are not trained to assist residents with medications. All cleaners/disinfectants, soaps/detergents, were all locked up and inaccessible to residents in care. Sufficient food supply for residents in care. Sufficient paper products, hygiene products, linens, and personal protective equipment (PPE) for use as needed. Front yard, the backyard deck and yard space was clean and orderly. All walkways were free and clear. The backyard emergency fire gate opened freely. LPA reviewed five (5) resident files, including medications and medication records. LPA reviewed four (4) staff files. All staff had required criminal record clearance. All staff had first aid and cpr certification as required. All staff had required training. Continued on LIC809C... LPA is requesting the following documents be updated and submitted by 3/25/25. LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required-submit copy of review page) If changes submit plan copy Infection Control Plan (ensure to review and update as needed/required- submit copy of review page) If changes to infection plan, submit copy Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Copy of Current Liability Insurance Resident Roster Copy of current Administrator Certificate No deficiencies cited today. Exit interview conducted with Administrator/Licensee Sheila Sumabat.