The Leisure Living Homes

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by Victoria Dominguez and explained the reason for the visit. Marjorie Hechanova, Administrator Assistant arrived shortly thereafter. The facility is licensed to serve residents ages sixty (60) and older, including up to six (6) non-ambulatory residents, of whom one (1) may be bedridden. Bedrooms #1, #2, and #3 are approved for non-ambulatory residents. Bedroom #4 is approved for a bedridden resident. The facility may retain no more than six (6) residents receiving hospice care. At the time of inspection, two (2) residents were receiving hospice services. There four (4) hospice resident at the time of the visit and two (2) on home health. Facility Tour & Observations Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. Oxygen was observed in use in the facility. Required “Oxygen in Use / No Smoking” signs were posted throughout the facility in visible locations. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present. Physical Plant The facility is in a residential area and is a one-story home consisting of five (5) resident bedrooms, living room, kitchen, laundry room, dining area, laundry room, garage, front yard, and backyard. LPA observed five (5) resident bedrooms, and all contained the required furniture (bed, mattress, linens, dresser, chair, and lighting). Cleaning supplies and toxic substances were inaccessible to residents locked in a kitchen cabinet under sink. Bathrooms were clean and equipped with required grab bars in showers and near toilets, as well as non-skid mats; hot water measured in bathroom (1) 111.2°F, bathroom (2) 109.5°F bathroom (3) 112.3 °F and which is within the required 105–120°F. Extra linens and towels were available in a hallway cabinet. Smoke/carbon monoxide detectors were functional; fire extinguisher mounted by the living room area. There were no bodies of water present. Backyard provided shaded seating. Passageways and exits were observed to be clear and unobstructed. (continued on 809C) Food Service Refrigerators and freezers were maintained at proper temperatures (refrigerators at a maximum of 40°F and freezers at 0°F) and contained a sufficient supply of food, including at least a two (2)-day supply of perishable food and a seven (7)-day supply of non-perishable food. Fresh produce, proteins, and dry goods were observed to be adequately stocked. Knives were observed stored in a locked kitchen drawer. Two additional refrigerators located in the garage contained extra food supply. A cabinet containing additional canned goods was also observed in the garage. Health-Related Services & Records Four (4) resident files were reviewed and were found to contain current required documentation, including Admission Agreements, Pre-Placement Appraisals, signed consents, Needs and Service Plans, Physician’s Reports documenting ambulatory status, Resident Rights acknowledgments, and medication records. Medication Administration Records (MARs) were observed and found to be complete and in compliance. Four (4) residents’ medications were reviewed. Medications were observed to be centrally stored in a locked cabinet located between the kitchen and laundry room. Disaster Preparedness Last fire/earthquake drill was conducted on January 5, 2026, with logs available. LIC 610D Emergency Disaster Plan was posted on front entry bulletin board. Emergency supplies (water, food, flashlights, batteries, first aid) were observed in the garage. Infection Control Plan was updated. Personnel Records & Training Three (3) staff files were reviewed and were found to contain criminal record clearances. Current CPR and First Aid certificates, tuberculosis (TB) screening documentation, and required training records were also observed in each staff file. Insurance Liability insurance was in compliance with an expiration date of April 2, 2026. At the time of the visit, the facility was found to be in compliance with Title 22, Division 6 regulations. No deficiencies were cited during the inspection. An exit interview was conducted with Administrator Marjorie Hechanova. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Feb 12, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an annual inspection visit on 3/18/2025 and was greeted by Caregiver Giselle Co. LPA Ramirez identified herself and explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected five (5) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed no-slip coating in showers. LPA Ramirez observed seated shower chairs in bathroom#1. LPA Ramirez video surveillance in common areas. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 01/25/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in facility office. See 809-C Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication closet and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services. During inspection of facility, LPA Ramirez observed residents’ receiving podiatry care. Staffing: Administrator Certificate for Gerry Hechanova 02/20/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for three (3) out of the three (3) personnel record reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel record reviewed. Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for six (6) non-ambulatory, of which one (1) may be bedridden. Bedrooms# 1,2,3 are approved for non-ambulatory. Bedroom#4 is approved for bedridden. This facility may retain no more than six (6) hospice residents. There are currently five (5) residents under hospice care. During resident record review, LPA Ramirez observed resident#1 (R1’s) medical assessment indicates R1 is bedridden. During facility tour, LPA Ramirez observed R1 is residing in bedroom#1. Per fire clearance, the facility may retain one (1) bedridden resident in bedroom#4 only. According to facility staff and R1’s recent medical assessment, R1 recently became bedridden. Licensee Hechanova reached out to R1’s responsible party and R2’s responsible party and all parties agreed to swap resident rooms. LPA Ramirez verified all parties agreed to swap. LPA Ramirez observed staff swapping residents' belongings into their new rooms. Resident Records/Incident Reports: LPA reviewed resident records for six (6) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were observed during this visit. Exit interview conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Mar 18, 2025

Allegation investigated: Unlawful eviction. Facility staff as is acting as substitute payee for resident.

Licensing Program Analyst (LPA) Tena Herrera conducted unannocuned compliant visit to investigate the allegations listed above. LPA was greeted by Semon Orbe (caregiver) and was later met by Marjorie Hechanova (Administrator) who assisted with the visit. The Investigation consisted of the following: LPA obtained copies of resident and staff rosters, reviewed R1's file and obtained relevant copies of documents within file, toured R1's bedroom and conducted interviews with staff at hospitals, facility administrator and 1 staff at facility. (continued on 9099-C) Unsubstantiated The investigation revealed the following: Allegation: Unlawful eviction. It is alleged that S1 has disclosed that they will not be allowing R1 back into the facility following a recent hospitalization. Per conversations with hospital staff, in which R1 has/had been hospitalized, S1 initially stated they will not be re-admitting R1 to facility upon discharge, however, recently S1 is now stating that they will need to reassess R1 prior to readmission. Per conversation with S1 they denied the above allegation and stated they have not evicted R1, nor have they submitted any eviction paperwork to Licensing. S1 stated that they will be reassessing R1 and make a determination on how to proceed following the reassessment. LPA provided S1 with information under Title 22 regulations for Reappraisals and explained to S1 that although R1 may not be fit for facility after discharge the facility must comply with Title 22 regulations and find a higher level of care for R1 if need be. S1 stated that if it is deemed that R1 will need a higher level of care they will work with R1's doctor to find proper placement for R1. LPA further explained to S1 that once R1 is ready to be discharged from hospital, the reassessment can be done after discharge, as there seems to be some trouble receiving documents needed for the reassessment. LPA also toured R1's room, this is a shared room, R1's bed is still vacant and R1 has their belongings in dresser within room. Allegation: Facility staff as is acting as substitute payee for resident. It is alleged that S1 has become R1’s payee and will be collecting funds for the month of August even though R1 will not be admitted back to the facility after their hospitalization. LPA interviewed S1 and S1 denied the above allegation, stating that when R1 was admitted to facility both S1 and R1 went to social security to designate S1 as the payee (which was agreed between family, R1 and S1), however, S1 has placed a hold on the paperwork for R1's family to be designated as the payee since then. S1 stated this was done as they feel the family is a better fit to be the designated payee. LPA spoke with sisters of R1 and it was agreed that family will be the payee for R1. Based on statements and interviews conducted with staff, and review of R1's file, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report will be provided via email to Administrator Marjorie Hechanova this evening.the state’s words, verbatim · CDSS document, Jul 11, 2024 · control 28-AS-20240702153715

Allegation investigated: Staff neglect led to resident sustaining pressure injury. Staff left resident unattended in soaking wet diaper for extended periods. Staff did not assist resident. Staff mismanaged resident's medication. Staff did not treat resident with respect.

*This is a corrected verison of previous 9099 dated 6/20/2024. LPA Ramirez corrected number of clients interviewed.No changes to findings.* Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 06/20/2024 regarding the above allegations. LPA Ramirez was greeted and allowed entry by Caregiver Semon Orbe. LPA Ramirez explained the purpose of the visit and Administrator Marjorie Hechanova, arrived shortly after to the facility. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 3 interviews (S1 – S3), Attempted interview of Resident#1 (R1), Interview of Residents#2-4 (R2-R4), copies of Resident#1-4 (R1-R4) Physician’s Report, Identification and Emergency Information form, Admission Agreement, Hospice Plan of Care, Hospice Care Narrative Notes, Medication Administration Record (MAR) for the month of June, copies of Staff#2-3 (S2-S3) application information and physical plant tour. SEE 9099-C Unsubstantiated The investigation revealed the following. Regarding Allegation: Staff neglect led to resident sustaining pressure injury- It is alleged R4 sustained an pressure injury while in care due to staff neglect. R4 was admitted into facility on 8/4/2021. R4 began receiving Hospice Care on 07/26/2023. LPA Ramirez reviewed hospice care plan that address wound care by hospice staff. Hospice care narrative note dated 6/12/24, revealed hospice staff observed R4 to be well cared for and hospice staff did not have concerns during visit. Three (3) out of the three (3) staff interviewed deny this allegation. Two (2) out of the three (3) residents interviewed denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview R1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff left resident unattended in soaking wet diaper for extended periods- It is alleged R4 was left unattended soaking in wet diaper for extended periods of time. R4 was admitted into facility on 8/4/2021. R4 began receiving Hospice Care on 07/26/2023. Hospice care narrative note dated 6/12/24, revealed hospice staff observed R4 to be well cared for and hospice staff did not have concerns during visit. During facility tour, LPA Ramirez observed facility staff providing R4 with grooming needs in R4’s bedroom. LPA Ramirez observed R4 to be well groomed and R4’s room was not observed to be odorous. LPA Ramirez observed more than 40 unopened bags of adult diapers in facility supply closet and garage. Three (3) out of the three (3) staff interviewed deny this allegation. Two (2) out of the three (3) residents interviewed denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview R1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. SEE 9099-C for continued narrative report. Staff did not assist resident- It is alleged staff do not assist R4 at night and remove R4’s call button. Three (3) out of the three (3) staff interviewed deny this allegation. Two (2) out of the three (3) residents interviewed denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview R1. During facility tour, LPA Ramirez observed R4 seated in a recliner in the living room. LPA Ramirez observed a 2in x 2in round-white and green call button pendant sitting on top of a side table next to R4. LPA Ramirez observed a green lanyard attached to pendant. Interview with R4 revealed R4 wears the pendant around their neck at night and will push the call button for assistance when needed. LPA Ramirez tested pendant and was observed to be in working order. During tour of resident bedrooms, LPA Ramirez observed four (4) cordless bed senor pads under resident mattresses. According to S2, these pads detect movement and alert staff. When staff hear the alert sound off, they will check in on the resident. LPA Ramirez observed these sensors to be in working order. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff mismanaged resident's medication- It is alleged staff mismanage R1’s medication by overmedicating R1. R1 was admitted into facility on 8/4/2021. R1 began receiving Hospice Care on 12/19/2023. Review of R1’s hospice plan of care, revealed facility staff were instructed to monitor medications and report to hospice staff. LPA Ramirez compared R1’s centrally stored medication to R1’s MAR for the month of June 2024. LPA Ramirez did not observe and discrepancies. LPA Ramirez observed MAR for June 2024, which staff logged “PRN” (as needed) medication for R1, was administered according to R1’s physician order. LPA Ramirez compared R2, R3 and R4 MAR against centrally stored medications, and did not observe discrepancies. Three (3) out of the three (3) staff interviewed deny this allegation. Two (3) out of the three (3) residents interviewed denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview R1. Although the allegation do not may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff did not treat resident with respect- It is alleged staff do not treat residents with respect. Three (3) out of the three (3) staff interviewed deny this allegation. Two (2) out of the three(3) residents interviewed denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview R1. Hospice care narrative note dated 6/12/24, revealed hospice staff observed R4 to be well cared for and hospice staff did not have concerns during visit. During tour, LPA Ramirez observed two (2) staff providing care and supervision. LPA Ramirez observed staff to be courteous and professional while caring for residents. Although the allegation do not may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited during this investigation. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 29, 2024 · control 28-AS-20240611161010

Allegation investigated: Staff neglect led to resident sustaining pressure injury. Staff left resident unattended in soaking wet diaper for extended periods. Staff did not assist resident. Staff mismanaged resident's medication. Staff did not treat resident with respect.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 06/20/2024 regarding the above allegations. LPA Ramirez was greeted and allowed entry by Caregiver Semon Orbe. LPA Ramirez explained the purpose of the visit and Administrator Marjorie Hechanova, arrived shortly after to the facility. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 3 interviews (S1 – S3), Attempted interview of Resident#1 (R1), Interview of Residents#1-3 (R1-R3), copies of Resident#1-4 (R1-R4) Physician’s Report, Identification and Emergency Information form, Admission Agreement, Hospice Plan of Care, Hospice Care Narrative Notes, Medication Administration Record (MAR) for the month of June, copies of Staff#2-3 (S2-S3) application information and physical plant tour. Unsubstantiated The investigation revealed the following. Regarding Allegation: Staff neglect led to resident sustaining pressure injury- It is alleged R4 sustained an pressure injury while in care due to staff neglect. R4 was admitted into facility on 8/4/2021. R4 began receiving Hospice Care on 07/26/2023. LPA Ramirez reviewed hospice care plan that address wound care by hospice staff. Hospice care narrative note dated 6/12/24, revealed hospice staff observed R4 to be well cared for and hospice staff did not have concerns during visit. Three (3) out of the three (3) staff interviewed deny this allegation. Two (2) out of the three (3) residents interviewed denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview R1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff left resident unattended in soaking wet diaper for extended periods- It is alleged R4 was left unattended soaking in wet diaper for extended periods of time. R4 was admitted into facility on 8/4/2021. R4 began receiving Hospice Care on 07/26/2023. Hospice care narrative note dated 6/12/24, revealed hospice staff observed R4 to be well cared for and hospice staff did not have concerns during visit. During facility tour, LPA Ramirez observed facility staff providing R4 with grooming needs in R4’s bedroom. LPA Ramirez observed R4 to be well groomed and R4’s room was not observed to be odorous. LPA Ramirez observed more than 40 unopened bags of adult diapers in facility supply closet and garage. Three (3) out of the three (3) staff interviewed deny this allegation. Two (2) out of the three (3) residents interviewed denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview R1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. SEE 9099-C for continued narrative report. Staff did not assist resident- It is alleged staff do not assist R4 at night and remove R4’s call button. Three (3) out of the three (3) staff interviewed deny this allegation. Two (2) out of the three (3) residents interviewed denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview R1. During facility tour, LPA Ramirez observed R4 seated in a recliner in the living room. LPA Ramirez observed a 2in x 2in round-white and green call button pendant sitting on top of a side table next to R4. LPA Ramirez observed a green lanyard attached to pendant. Interview with R4 revealed R4 wears the pendant around their neck at night and will push the call button for assistance when needed. LPA Ramirez tested pendant and was observed to be in working order. During tour of resident bedrooms, LPA Ramirez observed four (4) cordless bed senor pads under resident mattresses. According to S2, these pads detect movement and alert staff. When staff hear the alert sound off, they will check in on the resident. LPA Ramirez observed these sensors to be in working order. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff mismanaged resident's medication- It is alleged staff mismanage R1’s medication by overmedicating R1. R1 was admitted into facility on 8/4/2021. R1 began receiving Hospice Care on 12/19/2023. Review of R1’s hospice plan of care, revealed facility staff were instructed to monitor medications and report to hospice staff. LPA Ramirez compared R1’s centrally stored medication to R1’s MAR for the month of June 2024. LPA Ramirez did not observe and discrepancies. LPA Ramirez observed MAR for June 2024, which staff logged “PRN” (as needed) medication for R1, was administered according to R1’s physician order. LPA Ramirez compared R2, R3 and R4 MAR against centrally stored medications, and did not observe discrepancies. Three (3) out of the three (3) staff interviewed deny this allegation. Two (3) out of the three (3) residents interviewed denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview R1. Although the allegation do not may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff did not treat resident with respect- It is alleged staff do not treat residents with respect. Three (3) out of the three (3) staff interviewed deny this allegation. Two (2) out of the three(3) residents interviewed denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview R1. Hospice care narrative note dated 6/12/24, revealed hospice staff observed R4 to be well cared for and hospice staff did not have concerns during visit. During tour, LPA Ramirez observed two (2) staff providing care and supervision. LPA Ramirez observed staff to be courteous and professional while caring for residents. Although the allegation do not may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited during this investigation. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 28-AS-20240611161010

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Kimberly Ramirez conducted unannounced post-licensing inspection. LPA met with Administrator Marjorie Hechanova and explained purpose of today’s visit. This facility is licensed to serve six (6) residents over the age of 60, of which, five (5) non-ambulatory of which one (1) may be bedridden. Bedrooms #1,2,3, and 5 are approved for non-ambulatory. Bedroom#4 is approved for one (1) bedridden resident. This facility may retain no more than six (6) hospice residents. There are four (4) residents under hospice care at this time. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected five (5) rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be within 105 – 120 degrees F. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). Planned Activities: LPA Ramirez observed posted monthly and weekly activities poster in facility dining room area. Residents Rights-Information: LPA Ramirez observed the following postings: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line to be operational. SEE 809-C for contiued narrative report. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D) in place. Emergency drills were conducted quarterly. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply. Residents with Special Needs: No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication cabinet and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. LPA Ramirez compared four (4) residents’ medications to clients’ MAR. Staffing: Administrator Certificate for Marjorie Hechanova (6057186740) expires on 09/17/2024. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for three (3) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for five (5) non-ambulatory, of which one (1) may be bedridden. This facility may retain no more than six (6) hospice residents. There are currently four (4) residents under hospice care. Resident Records/Incident Reports: LPA reviewed resident files for four (4) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were cited during post-licensing inspection. Exit interview conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 20, 2024

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Ramirez and Gutierrez made an announced visit and met with Licensee Majorie Hechanova to conduct a Pre-Licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) on for an initial application of a Residential Care Facilities for the Elderly (RCFE) to serve adults ages 60 and over. A Dementia waiver and a hospice waiver for six (6) is in place. The requested capacity is for five (5) non-ambulatory, of which one (1) may be bedridden. Bedroom#4 is approved for one (1) bedridden resident. Bedrooms #1,2,3, and 5 are approved for non-ambulatory. Structure: Facility is a single-story home located in a residential area consisting of five (5) bedrooms, three (3) bathrooms, kitchen, dining room, living room, laundry area in attached garage, backyard with outdoor covered patio, storage shed in the rear of the backyard. Front yard is landscaped with grass and back yard is landscaped with paved walkway. Bedroom Clients: Bedroom#1, 3, 4 and 5 are private. Bedroom#2 is shared. Bedrooms are equipped with one bed, nightstand, chair, lamp, and overhead lighting. Bathrooms: Two (2) full bathrooms equipped with working toilets, wash basins, bathtub/ walk-in shower. Bathroom#3 is located in staff office and is a half bathroom. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in linen closets. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. One (1) fully charged fire extinguisher was observed. Facility has a land line telephone. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Emergency water supply was observed. Smoke Detectors: There are electrical & inter-connected smoke detectors located in all bedrooms, common areas, and hallways. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer are in good condition. The residence is equipped with central heating and air conditioning. Toxins: Cleaning supplies, and toxins are locked only accessible to staff. ***Narrative continues next page.**** Water Temperature: Hot water was tested in all bathrooms, and kitchen sink. Water temperature was within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C). Medication, First-Aid Kit & Book: Designated centrally stored medications cabinet, and the first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. Resident & Staff Files: Designated area for files will be in staff office. Pools/Jacuzzi/Body of Water & Pets: No bodies of water were observed. No health and safety concerns were observed. Fire Clearance: Fire clearance was approved on 2/29/24 for 5 non-ambulatory, and 1 bedridden in room#4. Component III: Component III was waived. Applicant is presently a Licensee of another other RCFE. An exit interview was conducted and a copy of this report has been furnished to Majorie Hechanova. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Mar 20, 2024