Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA was met by Eva Nainggolan, Direct Care Staff/DSP II and explained the purpose of the visit. The Administrator, Trupti Mody was called on the phone. The facility is licensed to serve (4) non-ambulatory residents ages 60 and above, of which (1) may be bedridden. Bedroom #5 is approved for the bedridden resident. Facility cares for dementia residents and has a hospice waiver approved for (4) residents. The facility is vendorized by the San Gabriel/Pomona Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathroom has hygiene items such as hand soap and toilet paper. Staff are trained in the proper use of required PPEs.

Operational Requirements: A fire clearance is in place. Facility has signal systems in exit points but some are inoperable. Liability of insurance is not readily available for review in the facility. Surety bond is valid in the amount of $3000 and expires on 09/29/2026. There are (2) fire extinguishers in the facility which was last serviced on 02/10/2026.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that consists of (4) resident bedrooms, (2) staff bedrooms, (2.5) bathrooms, living room with a fireplace, activity room, kitchen, dining area, backyard with a covered patio and equipped with outdoor furniture and attached garage with a laundry area. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. There are video surveillance in the common areas of the facility . Facility has interconnected smoke detectors and carbon monoxide detectors at the home. Knives, cleaning solutions, and disinfectants are locked. Sufficient food supplies are observed. The facility has a dementia care plan to accept or retain residents with dementia. There are no firearms or weapons stored at the facility. Water temperature reading measured at 107 deg F in bathroom #1 and 109.2 deg F in bathroom #2 which are within the required 105 - 120 degrees Fahrenheit. *****REPORT CONTINUED ON LIC809-C****