Routine inspection·August 20, 2025

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:08 A.M. The LPA was greeted by Caregiver Ari Lutfi Mahendra and informed the reason for the visit. Caregiver contacted the Administrator by phone, Shila Pandey. At 10:25 A.M. the Administrator arrived at the facility. At 10:38 A.M., the back-up Administrator, Karthiga Vijayakumar joined the visit. LPA explained the reason for the visit. Entrance interview conducted. Beginning at 10:48 A.M., the LPA along with the Administrator and back-up Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Hardwired smoke detector and Carbon Monoxide detectors were tested at 11:41 A.M. and were functional at the time of the visit. LPA observed one (1) fully charged fire extinguisher purchased on 10/28/2024. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 7 (seven) bedrooms in total; 1 (one) of which is designated as a staff room and 6 (six) are private resident rooms. Staff room was observed locked. There were no visible hazards or discrepancies observed. RESTROOMS: The LPA observed 3 (three) restrooms in the facility; 2 (two) are shared restrooms and one is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Water temperature were measured in all bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit. 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, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened and inaccessible to residents. Auditorial signals were observed in each door around the facility. The facility maintained a comfortable temperature of 68 degrees Fahrenheit. OUTDOOR SPACE: The backyard has a shaded seating area for residents to enjoy. The facility has one (1) side gate. The gate was observed to be self-closing and self-latching. The LPA did not observe any obstructions to emergency exit pathways. The garage is attached to the house and locked at all times. Garage contained the laundry area, extra food, emergency water and additional mobility devices. Cleaning supplies and chemicals are stored and inaccessible to residents. Emergency water is stored in the garage. KITCHEN : Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. At 11:20 A.M., hot water temperature measured 114.8 degrees Fahrenheit. RECORD REVIEW: Record review began at 11:54 A.M., records were reviewed for but not limited to: health screening, TB test, staff training records, CPR certificate, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All records were in compliance with regulations. LPA reviewed four (4) staff files including the administrator’s file; all four (4) files reviewed were complete. MEDICATION REVIEW: Medications were observed locked in a cabinet across from the kitchen. The review began at 1:45 P.M. Medications for 4 (four) residents were observed. All residents' medications were observed to be maintained and administered in compliance with regulation. LPA requested the following documentation, Personnel Record (LIC 500), Resident Roster (LIC 9020), and current liability insurance. Last emergency disaster drill was conducted on 06/30/2025. Additionally, LPA observed emergency disaster plan to be complete and updated annually, as required. Facility has procedures in place regarding the infection control plan; however, the LIC 9282, as required by the department was not available for review. Technical Violation (TV) issued. Exit interview conducted. No deficiencies cited. A copy of the report was provided to the Administrator.