Facility Evaluation Report

Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Licensee Rey John Bertulfo and Administrator Ivy Jane Bertulfo and explained reason for visit. The facility is licensed for an age range 60 and over. Fire clearance approved for six (6) non-ambulatories where four (4) can be bedridden in room #5,6,7 and 8. Room #3 and #4 is for non-ambulatory only. Waiver/granted for hospice care for six (6) residents. Facility is a single-story home located in a residential area off of a main street consisting of eight (8) bedrooms; 6 private resident bedrooms and 2 staff bedrooms, 10 bathrooms, kitchen, dining room, living room, two (2) covered fireplaces (1 electrical fireplace & 1 gas), laundry room, large backyard outdoor covered patio, storage structure in the rear, and attached garage.

LPA toured the facility and observed the following: Each resident bedroom has the required furniture and bedding. LPA observed cameras in each resident’s bedroom that can be viewed on an app called LA view from staff I pad. Extra linen was observed in hallway storage cabinets. The Smoke detectors and carbon monoxide detectors were observed throughout the facility and are properly operating. The facility has multiple fully charged fire extinguishers located throughout the facility. Cleaning supplies and toxic substances were observed to be inaccessible in a locked cabinet in laundry area, knives were locked in kitchen cabinet. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Facility was observed to have sufficient supply of 7 days non-perishable foods and enough 2-day perishable foods for three (3) residents. During tour of facility LPA observed an open can of Budweiser beer in bathroom #4, a case of unopened beer in laundry room, and a trash can in garage filled with empty beer cans. Staff stated they had a late holiday party and residents were asked not to go outside during the party. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The resident bathrooms have the required grabs bars and non-skid mats. Bathroom #3 sink was not working. LPA observed a file cabinet with key in lock with residents’ medication accessible to residents in care. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents in backyard. LPA observed chairs, metal and other debris in back yard.

***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection. ***Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided.