Facility Evaluation Report

Licensing Program Analyst (LPA) Sanjay Vaid conducted an unannounced annual inspection visit. LPA met with Lead Caregiver Cynthia Dominguez, who allowed entry to the facility. Administrator Monica Aguilera arrived shortly after and assisted with the annual.

The facility is licensed to serve six (6) non-ambulatory residents who are ages 60 and above and approved for six (6) Hospice Waiver. Facility has dementia program on file. Currently, three (3) residents are on hospice. Annual licensing fees are current. Administrator certificate has expire 09/2025, pending.

During the visit, LPA conducted staff/resident interviews, used inspection tools, toured the facility, reviewed food supply, reviewed medications, and reviewed staff/residents’ records.

The facility is a single-family home located in a residential neighborhood, consisting of six (6) bedrooms, three residents (3) bathrooms, and one (1) staff bathroom, living room, dining room, activity/sunroom, laundry room, kitchen, and indoor/outdoor activity areas. Sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary, extra food supplies, toxins and cleaning products are stored in the garage, access via coded door lock. Medications were centrally stored, locked and inaccessible to residents in care. All the rooms are furnished with appropriate furniture for residents’ comfort. Bathrooms are furnished with grab bars and nonskid surfaces. Hot water temperature is measured at 109.7- 112.4 degrees Fahrenheit which is within Title 22 Regulation guidelines. Sufficient linen supplies and personal hygiene supplies are observed in hallway closets and garage storage area. Auditory device alarms are operational. Smoke detectors and carbon monoxide detectors were tested and operable. Four (4) Fire extinguishers were fully charged and last service was on 03/03/2026. The outdoor area has a shaded area and seating. The facility has sufficient staff, and the staff have current CPR/first aid certification, are over the age of 18 and are fingerprint cleared and associated with the facility. The Complaint, ombudsman and CCLD poster are posted by entry. The last fire drill was conducted on 04/16/2026. Liability Insurance expires 03/27/2027.

No deficiency was cited per California Code of Regulations, Title 22.

An exit interview was conducted and copy his report is discussed and provided to the administrator, whose signature on this form confirm receipt of this document.