Ad1 Residential Care

Type of visit: Required - 1 Year

Licensing Program Analysts's (LPA) Melina Oropeza and Kesha Lewis arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA's was met by staff and administrator joined 15 minutes later. LPA's explained the purpose of the visit to Administrator and staff. Administrator certificate # 7027415740 expires 02/10/2028. LPA's and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 6. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care. LPA's also conducted the care tool. No bodies of water were observed at the facility. Hot water temperature was measured at 106 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA's observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point. LPA's observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings. LPA's observed, fire extinguishers inspected on 11/13/2025 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance. LPA's reviewed three (3) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA's reviewed three (3) resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place. Exit interview held with administrator and copy of report left at conclusion of visitthe state’s words, verbatim · CDSS document, Apr 3, 2026

Type of visit: Required - 1 Year

Unannounced Annual visit made out to this facility on 05/01/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated representative, Chai Damrichob, who was briefly interviewed at this time. This LPA requested that he go ahead and contact the facility designated Administrator, Orchid Damrichob, to inform her that CCL was present at this time for an annual visit. The facility designated representative conducted this annual visit along with this LPA and represented the facility designated Administrator at this time. Current census was 6 residents. It was learned that there were (3) residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (5) residents under the care of hospice at any given time. It was learned that there was (1) resident receiving services through home health at this time. It was learned that there were (3) residents diagnosed with dementia at this time. This facility does have a program to accept and retain residents diagnosed with dementia at this time. Tour of this facility was conducted. Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet, located underneath the stairway, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time. Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured. Laundry room, located in the garage area, was toured. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Administrator certificate, # 7027415740, for Orchid Damrichob was observed to have an expiration date of 02/10/2026 and in compliance at this time. Forms and documents have been completed in order to renew this Administrator certificate at this time. Medication cabinet, located in the facility kitchen cabinet, was observed to be locked and made inaccessible to the residents at this time. First aid kit, located in the medication closet, was reviewed. This LPA observed that it did contain all of the required components at this time. Fire extinguishers were located throughout this facility and observed to have been annually inspected by the local fire extinguisher company, Jorgensen Fire Company, on 01/06/2025 and found to be in compliance at this time. Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted. A review of (3) facility personnel records was conducted on the LIC 859. A review of (5) facility resident records was conducted on the LIC 858. The following forms and documents were requested to be updated and submitted into CCL for review by this LPA: LIC 308 LIC 400 LIC 500 LIC 610 There were no deficiencies observed or cited during today's annual visit. Exit Interviewthe state’s words, verbatim · CDSS document, May 1, 2025

Type of visit: Post Licensing

Unannounced Post Licensing visit made out to this facility on 07/08/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility Administrator, Orchid Damrichob, who was briefly interviewed at this time. Current census was 6 residents. It was learned that there were (3) residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (5) residents under the care of hospice at any given time. It was learned that this facility will has a program to be able to accept and retain dementia residents at any given time. It was learned that there were (3) residents diagnosed with dementia at this time. It was learned that there were (2) residents receiving services through home health at this time. Tour of this facility was conducted. Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet, located in facility employee office, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time. Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Additional food storage units were observed to be present and functional at this time. Laundry area, located in the garage area, was toured. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Administrator certificate, # 6066497740, for Cecil De Lara was observed to have an expiration date of 03/21/2025 and in compliance at this time. Medication cabinet, located in the facility kitchen area, was observed to be locked and made inaccessible to the residents at this time. First aid kit, located in the kitchen cabinet, was reviewed. This LPA observed that it did contain all of the required components at this time. Fire extinguishers, located throughout this facility, were observed to have been annually inspected by the local fire extinguisher company, Armor Fire, on 01/21/2024 and in compliance at this time. Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted. This LPA observed an additional storage shed that were present on the north side of this facility at this time. This storage shed was observed to be locked and made inaccessible to the residents at this time. A review of (3) facility personnel records was conducted on the LIC 859. A review of (3) facility resident records was conducted on the LIC 858. There were no deficiencies observed or cited during today's post licensing visit. Exit Interviewthe state’s words, verbatim · CDSS document, Jul 8, 2024

Type of visit: Prelicensing

Announced Prelicensing visit made out to this facility on 04/19/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility Applicants, Chai and Orchid Damichob, who were briefly interviewed. This LPA later met another facility staff person, Cecil De Lara, who will be the facility designated Administrator. Current census was 0 residents. It was learned that this facility will be seeking to accept and retain up to (5) residents under the care of hospice at any given time. It was learned that this facility will have a program to be able to accept and retain dementia resident at any given time. Tour of this facility was conducted. Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet, located in facility employee office, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time. Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Additional food storage units were observed to be present and functional at this time. Laundry area, located in the garage area, was toured. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Administrator certificate, # 6066497740, for Cecil De Lara was observed to have an expiration date of 03/21/2025 and in compliance at this time. Medication cabinet, located in the facility kitchen area, was observed to be locked and made inaccessible to the residents at this time. First aid kit, located in the kitchen cabinet, was reviewed. This LPA observed that it did contain all of the required components at this time. Fire extinguishers, located throughout this facility, were observed to have been annually inspected by the local fire extinguisher company, Armor Fire, on 01/21/2024 and in compliance at this time. Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted. This LPA observed an additional storage shed that were present on the north side of this facility at this time. This storage shed was observed to be locked and made inaccessible to the residents at this time. The following forms and documents were requested to be updated and submitted into CCL: LIC 308 LIC 400 LIC 500 LIC 610 This facility was found to be in compliance at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Apr 19, 2024