Good Samaritan Guest Home III

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility administrator Susana Cambio after stating the purpose of the visit. Administrator Leo Cambio also arrived shortly afterwards to assist with the visit. There are currently five residents in care, none of which is receiving hospice care at this time. Residents are observed relaxing in their respective bedrooms and having lunch in the facility's kitchen. Flooring renovation is under way in the caregiver room and living room. Resident bedrooms flooring have been replaced the day leading up to the visit. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with two shared bedrooms and one single bedroom, along with one room used by overnight caregiving staff. There are two shared bathrooms used by residents. None of the residents are bedridden at this time. All occupied bedrooms appear clean and sanitary. All resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary and are all equipped with grab bars and slip mats. Hot water temperature measured at 109F in the shared bathroom. Unsecured cleaning products observed under one of the bathroom sinks as well as in the kitchen. Type B deficiency cited. LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items are verified to be secure in a locked cabinet in the kitchen. The medication central storage is in a locked cabinet inside the caregiver room. CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 Wall-mounted fire extinguishers are present and verified to be charged, however maintenance tags are not present and maintenance could not be verified. Type B deficiency cited. Carbon monoxide and smoke detectors were found to be present and operational. Emergency water supplies are stored in the garage. LPA and facility staff toured the outside of the facility. LPA observed a shaded outdoor seating area with outdoor furniture for resident use in the backyard. The identified route of egress is free of clutter and obstructions. There are self-latching gates on both sides of the premises. There are no bodies of water on the premises and the facility does not utilize either locked perimeters or delayed egress. LPA reviewed five resident records. All necessary elements of documentation are present per Title 22 requirements. Physician reports are up to date for all residents LPA reviewed staff records for four staff members during the visit. Proof of current CPR training reviewed. Disaster drills are conducted quarterly. The administrator certificates are current. Initial and annual training records are present and meet Title 22 requirements. All staff members on the roster are verified to be cleared and associated to the present licensed location Based on the observations conducted during the present visit, two type B deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.the state’s words, verbatim · CDSS document, Dec 2, 2025

Type of visit: Required - 1 Year

On this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry by facility administrator Leo Cambio after stating the purpose of the visit. There are currently five residents in care, none of which is receiving hospice care. LPAs observed residents relaxing in the facility’s common area or in their respective bedrooms. LPAs accompanied by facility staff toured the physical plant. The facility is a one-story house with an attached garage. The facility has two shared and one private bedrooms with one shared bathroom for residents and one shared bathroom for staff members. Bedrooms appeared clean and sanitary. LPAs observed all the resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Bathrooms are equipped with grab bars and non-slip mats. Hot water temperature measured at 110F. LPAs observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. LPA observed knives locked in a secure drawer. A fire extinguisher is verified to be charged and mounted to the wall. Annual maintenance is however not apparent. Staff stated the fire extinguisher was bought new earlier in 2024. Consultation provided. LPAs tested the smoke and carbon monoxide detectors which were found to be operational. The centrally stored medication is located in a locked cabinet in the staff bedroom. The attached garage is inaccessible to residents and is used for storage and for laundry. Cleaning supplies are stored in the garage. LPAs and facility staff toured the outside of the facility and observed it to be free of obstructions. LPAs observed two shaded outdoor seating areas with furniture for resident use. The perimeter gates on one side of the property is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises. CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 LPAs reviewed five resident records which included all necessary components. LPAs reviewed resident medication records and found the Medication Administration Records to be outdated for one resident out of five. Prescription orders verified for all five residents. Consultation provided. LPAs reviewed two staff records which were found to be complete. Training and CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately. Infection Control and Emergency and Disaster plans were both reviewed and are complete and accurate. Fire and emergency drills are conducted quarterly. Drills are documented on the Emergency and Disaster Plan itself rather than on a separate document. Consultation provided. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Three consultations provided. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Dec 16, 2024

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.