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Type of visit: Required - 1 Year

On 9/30/2025 at approximately 09:45 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the Administrator, Lucia Dela Rea and stated the reason for today’s visit. LPA asked for the census, Staff/Resident Roster, and Liability Insurance. LPA conducted a physical plant tour at approximately 11:00 AM and the following was noted: The facility is a single-story building with six (6) bedrooms and three (3) bathrooms. The facility is currently occupying five (5) residents. There is a designated staff room. The facility has an approved fire clearance for six (6) non-ambulatory residents of which one (1) may be bedridden. Hospice waiver approved for six (6). Common areas: The living rooms and dining rooms were observed to be neat, clean, and organized. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 75°F. LPA observed a fire extinguisher to be located near the kitchen and dated 09/02/2025. LPA observed required postings such as Long-Term Care Ombudsman, See/Say Something, and Personal Rights to be located throughout the common areas. A working telephone was observed. LPA observed the fireplace to be covered and inaccessible to residents. Kitchen: The kitchen was observed to be clean and free from pests. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. Knives/sharps were observed to be kept in a locked kitchen drawer. The cleaning solutions/toxins were observed to be kept locked underneath the kitchen sink. Kitchen appliances were observed to be working and in proper condition. (continued on LIC 809-C) Bedrooms: The residents’ rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Extra linens/covers were observed to be stored in storage closet located within the hallway’s passageway. Staff Room: LPA observed staff room to be locked. Bathrooms: The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured within regulations. LPA observed appropriate grab rails and slip-resistant mats to be in proper condition. Backyard: The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. There is no body of water located at the facility. Garage: The garage can be accessed from inside the facility. The garage was observed to be kept locked and used for storage purposes. Extra refrigerator and freezer with additional food for residents was observed. Laundry Room: The laundry appliances were observed to located within the garage. LPA observed cleaning solutions and toxins stored appropriately within the laundry room and inaccessible to residents. The laundry appliances were observed to be working and in proper condition. Medications: The medications were observed to be kept in locked kitchen cabinet. Staff and residents’ files were observed to be kept in a locked filing cabinet located near the kitchen. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer and First-Aid Manuel. Smoke detectors and carbon monoxide observed to be working properly and were tested. Residents/Staff Records: LPA conducted a complete file review of resident records. One (1) of one (1) resident on Home Health did not have their complete file. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated. Citation issued. Please refer to LIC 809-D There were no other immediate health and safety hazards observed during the day of inspection. Exit interview conducted, Appeal Rights given and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 30, 2025

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan, met with Administrator Lucia Dela Rea for a One (1) Year Required visit for this facility. LPA arrived and was greeted by staff Eric Padua and explained the reason for the visit. Ms. Dela Rea arrived within three (3) minutes. There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted indoors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. A tour of the physical plant was conducted with the administrator at 1:25 PM. The facility is a single storey building with six (6) bedrooms and three (3) bathrooms currently occupying four (4) residents. One (1) bedroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents. Hospice waiver for six (6) residents. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 75°F. The smoke detector is hardwired and inter connected, tested and observed to be operational. The fire extinguisher is located in the kitchen and was observed to be full and last bought on 07/21/24. (continued on LIC 809-C) The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is small fountain located at the backyard but has no water. The garage is attached to the home and also being used as storage and laundry area. Laundry detergents, cleaning solutions and other toxins are locked in the cabinet and inaccessible to residents. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Dishwashing liquids and other cleaning supplies were stored in the kitchen cabinet and observed to be locked and inaccessible to residents. All sharps and knives were also observed to be locked in a kitchen drawer. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit to non-private rooms. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. Staff Rooms: Staff room is observed to be locked. No medications are observed in the staff room. The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at 110.6.°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet. Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. There is a complete first aid kit located in the medication cabinet. Client records: All four (4) client records are reviewed. Client records appeared to be complete and updated. Staff records: Staff record appeared to be complete and updated. Disaster drill was last conducted on 10/07/2024. Required posting are observed to be complete and current and displayed properly at the facility. Exit interview conducted and copy of this report issued.the state’s words, verbatim · CDSS document, Oct 12, 2024