Pendleton House

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Mary Karibian for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 09:30 AM and the following was noted: The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The facility is fire cleared for six (6) non-ambulatory, of which six (6) may be bedridden and a hospice waiver for six (6). The facility is currently occupying six (6) residents. The living and dining room are neat and clean. The facility has a total of four (4) bedrooms for residents and two (2) bathrooms.The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. (continued on LIC 809-C) Knives and sharps are observed to be locked and inaccessible to residents. Laundry detergents, cleaning agents and other toxins are locked away. The facility maintains a comfortable temperature at 75°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the kitchen and observed to be fully charged and last inspected January 21, 2026. The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 112.5°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, May 29, 2026

Type of visit: Required - 1 Year

On 04/08/2025, Licensing Program Analyst (LPA) de la Cerra arrived at the facility at 10:30am to conduct an unannounced annual inspection. LPA met with the facility administrator and LPA informed administrator the purpose of the visit. At approximately 11:00am LPA and administrator toured the facility and the following was observed. The facility is a single-story building that consist of five (5) bedrooms and two (2) bathrooms. LPA observed one (1) fully charged fire extinguisher. LPA observed the required facility postings in the common area. The facility provides a telephone for clients to use and LPA observed the phone to be operational. LPA observed dual smoke/carbon monoxide detectors that are hard wired and interconnected. Administrator tested the dual smoke/carbon monoxide detector @11:50am and was observed to be operational. Bedrooms: There is one (1) bedroom for staff use and four (4) bedrooms designated for residents to use. Resident rooms were observed to have sufficient lighting. All bedrooms are furnished with a night stand, a chair, a lamp, a closet and a bed with clean bedding and linens. Bathrooms: LPA observed two (2) bathrooms that are in good repair. The hot water temperature measured between 106°- 109°F. LPA observed the appropriate grab bars by the toilet and in the shower area. LPA observed the appropriate non-skid mats in each bathroom. Common Areas: The living room appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. KITCHEN: The facility has a kitchen area that is equipped with a refrigerator, stove and microwave. There is an adequate supply of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Sharps and knives were observed locked in a kitchen cabinet. Laundry Area: LPA also observed the washer and dryer located in the detached garage and both appear to be in good condition. LPA also observed a locked cabinet that stores laundry detergents and some cleaning solutions, Surrounding grounds: No bodies of water observed at this facility. LPA observed 2 seating areas for residents to use. The backyard seating area is shaded and both seating areas has furniture to accommodate the residents. The passageways and entrance to the home was clear of obstruction. Facility Records: At 1:00pm LPA conducted review of residents’ records and staff records. LPA reviewed six (6) out of six (6) client records and two (2) staff records to ensure compliance. The facility files were kept in locked cabinet located in the common area. Medications: The medications were kept in locked cabinet in the common area and is inaccessible to residents in care. The first-aid kit is complete. At approximately 1:51pm medications and medication records for two (2) residents were reviewed for proper documentation. Centrally Stored Medication Records are pre-filled by pharmacy and facility keeps a Medication Administration Record (MAR). Administrative: LPA received copies of the following; LIC 500, LIC 9020, liability insurance and administrator certificate. No deficiencies cited during today's visit. Copy of this report, was provided to the administrator.the state’s words, verbatim · CDSS document, Apr 8, 2025

Type of visit: Required - 1 Year

On 01/09/2024 at 09:00 AM, Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – Annual Continuation Inspection and met with Administrator Mary Maro Kariban four (4) residents and two (2) staff were present during this inspection. Facility Is following COVID mitigation protocols. At 09:30 AM LPA Alemoh conducted a physical plant to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Facility temp noted at 75 degrees. Facility is licensed to serve elderly residents aged 60 and above. Facility is cleared for non-ambulatory and bedridden residents. Facility also has an approved hospice waiver for 6 (6) residents. The Annual Licensing Fees are current. The facility is a single-story structure with four (4) Resident rooms: Rm 3 and Rm 4 serve two (2) bedridden residents, Rm 1 and Rm 2 serve one (1) bedridden resident, staff room, living room, dining room, and kitchen. LPA accessed facility through rear alleyway. S1 accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There were four (4) bedrooms designated for residents' all rooms were properly furnished with appropriate beddings and linens with sufficient lighting. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. (Cont From 809) There are two (2) bathrooms designated for residents' use. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 110F-111F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Laundry area is located in the garage LPA observed area to be clean and appliances in good repair. PPE’s and emergency supplies are stored in two (2) industrial sized cabinets, both are locked and secured. LPA toured the kitchen area and observed a two day supply of perishable and a seven day supply of non-perishable food in cabinets above the countertop. Knives were stored in locked cabinet and toxics were observed under the sink inaccessible to residents. Appliances observed to be in good repair and functioning. First Aid kit and manual was attached wall near the backyard entrance. There is One (1) fire extinguishers in the facility. Extinguisher was observed to be charged with receipt dated May 23rd, 2023. Dual Smoke alarms and carbon monoxide are hardwired and interconnected, were tested and observed to be operable. Fire/earthquake drills are completed quarterly. At 10:13 AM LPA conducted a file review. LPA reviewed three (3) staff records, 3 out of 3 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions. LPA reviewed five (5) resident records were reviewed and, 5 out of 5 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. Medication and Medication Records were reviewed for proper documentation. No deficiencies cited. An exit interview was conducted. A copy of this report and appeal rights were left with Administrator Mary Maro Kariban.the state’s words, verbatim · CDSS document, Jan 9, 2024