Routine inspection·June 3, 2025

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. LPA met with facility administrator, Flordeliza “Baby” Hipolito, and explained the reason for today’s visit. Entrance interview conducted. At 10:00 A.M. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This facility is a two-story building. On the ground floor, this facility has twelve (12) rooms and two full and three half (2 full and 3 ½) bathrooms. The second floor contains eight (8) rooms and two and a one half (2 full and 1 ½) bathrooms. T his facility doesn’t have a staff room, facility will provide 24/7 care. The following was observed. BEDROOMS: Resident bedrooms appeared to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are twenty total bedrooms, all of which were observed during the facility tour; four are private resident rooms and sixteen are shared resident rooms. Carbon monoxide detectors were observed in each room; randomly chosen detectors were tested and functioned properly. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed sufficient amounts of soap and paper products in each restroom. Between 10:10 A.M. and 10:45 A.M. hot water temperature was tested in a sampling of resident restrooms, which was measured at 112.2 – 117.4 degrees Fahrenheit, which is within the required range. Continued on LIC 809-C Continued from LIC 809 COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating areas and dining room furniture were observed to be in good condition. The LPA observed the required postings in the common hallway. The temperature inside the facility was maintained at a comfortable level throughout today's visit. The LPA observed cameras in the common areas. A working telephone is present. Fire extinguishers were observed to be fully charged and last serviced on 8/27/2024. Fire inspections are conducted annually by Integrated Fire Safety (IFS). The last inspection was conducted on 7/17/2024. IFS also conducted the facility's five-year inspection of the fire sprinkler system on 2/9/2023 with no concerns noted. KITCHEN : LPA observed the kitchen/dining area. Kitchen appliances appear to be in operable condition. LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods, including emergency supply and water. Cook stated that the facility uses Sysco for their food supply and delivery takes place every Tuesday. All knives and cleaning supplies were observed to be locked and stored in compliance with regulation. OUTDOOR SPACE: The outdoor area has two covered outdoor seating areas equipped with furniture for residents' use. An outdoor space is designated for smoking. There were no bodies of water observed. RECORD REVIEW: Between 11:30 A.M. and 1:35 P.M. LPA reviewed staff and resident records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisals, and admission agreements. The seven (7) staff files reviewed contained all documents. Separate training binder is maintained for all staff training. All nine (9) residents' files reviewed were missing consent for emergency medical treatment form (LIC627C), technical violation issued (TV). All other necessary forms were in compliance. Additionally, LPA observed that the Emergency Disaster Plan and the Infection Control Plan had not been updated with the required annual signatures. The Administrator reviewed and updated both plans during today’s visit. Technical violation issued. Last emergency drill was conducted on 04/30/2025. Continued on LIC 809-C Continued from LIC 809-C MEDICATION REVIEW: Medication is kept locked in the medication room on the ground floor. At 1:50 P.M. LPA reviewed medications for five (5) randomly chosen residents. All medications appeared to be given as prescribed, however, three (3) resident’s medication list with current centrally stored medication were missing. INTERVIEWS: LPA interviewed two (2) staff and two (2) residents; no concerns were noted. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.