Routine inspection·June 16, 2025

On 06/16/2025 at 1:30 PM, Licensing Program Analyst (LPA) Triel Ellen LIndstrom arrived at the facility unannounced to conduct a required annual inspection and was greeted by Licensee/Administrator Edith Rodriguez (#7013119740). The LPA identified herself and explained the purpose of the visit. Licensee accompanied the LPA on a tour of the physical plant, including inside and outside areas, to ensure that there were no health and safety hazards. This facility is a residential home with four bedrooms. At the time of this site visit, the census was four residents. All four residents are non-ambulatory, although one resident can walk around with a walker. A Caregiver arrived at the facility at 1:40 PM. The second administrator of the facility Samuel Rodriguez (#6067581740) arrived at the facility at 2:30 PM. The LPA entered the facility and observed the required postings on a bulletin board to the right of the entry door, including personal rights, mandated reporting, emergency plan, ombudsman information, facility license, and the administrators' certificates. The LPA toured the living/dining room and observed five recliners, a television, and several side tables. There were two residents sitting in recliners in the living room; one was asleep. LPA also observed a dining table with four chairs.The fire extinguisher hung from the wall between the living room and kitchen and was last serviced in October 2024 by ARF Fire Extinguisher Co.of Modesto. The LPA toured the four bedrooms and observed the required furniture in good repair, including beds, dressers, night stands, chairs, and lamps. The bedroom that is presently occupied by two residents has a private bathroom that contained non-slip flooring, grab bars, a toilet chair and a shower chair. The water temperature was 111 degrees Fahrenheit. The LPA toured a second bathroom in the hallway. This bathroom also contained non-slip flooring, grab bars, and shower and toilet chairs. The LPA observed a carbon monoxide detector in the hallway and a smoke detector in the living room and hallway. The Licensee tested the detectors and the alarm sounded. The LPA toured the garage, which was accessed by a door at the end of the hallway. The garage contained a water heater and staff belongings. The garage is not accessed by residents. The LPA toured a second living room that runs the length of the building. This room contained the washer and dryer. Laundry soap and other cleaners were stored in locked sheds in the back yard. The LPA toured the backyard. The yard contained three locked sheds used to store disposable briefs and cleaning supplies. Both side gates are self-closing and latching. There is a paved shaded area with enough furniture for residents and their families. The LPA toured the kitchen and observed a small dining room table with three chairs. The residents eat here and at the larger dining room table. The central medication storage is located in a locked pantry in the kitchen. It contained residents' medication in separate storage containers. All medication was in their original containers with labels intact. The LPA observed the first aid kit, which contained the required elements. The LPA observed that the facility's paper-based Medication Administration Record was missing. The Administrator stated that she left it somewhere else yesterday and did not record yesterday PM or today AM medication administration. The LPA reviewed the staff and resident records and found them complete. All staff has a criminal background clearance recorded in Guardian and valid first aid certificates. The LPA requested that updated copies of these documents be submitted to the Department by 5:00 PM on 06/23/2025: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (3) LIC 610 Current Emergency Disaster Plan (4) Proof of Current Liability Insurance (5) LIC 500 Current Personnel Report (6) LIC 309 Administrative Organization As a result of this annual visit, one deficiency was cited (see LIC809-D). The facility is not in compliance with Title 22 Regulation. An exit interview was conducted with the Licensee/Administrator and a copy of the LIC 809, LIC 809-D, and appeal rights were provided to the facility.