Facility Evaluation Report

Licensing Program Analysts (LPA) Sarah Hurt and Shawna Doucette conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator Cherry Agravante (via facetime) Continual Administrator's Certification expires 03/17/2026. There are currently 5 residents who reside at this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 117 degrees. Toxins and cleaning supplies are locked and inaccessible. LPA reviewed the facilities Plan of Operation, 3 staff files, and 2 resident files, Disaster drills, and Infection control plan.

LPA's observed Resident 1 does not have "basic rate" on admission agreement as required.

Staff 1 does not have required tuberculosis test on file. Resident 2's medication is not listed on Centrally Stored medication record. Resident 1's medication is listed on Centrally stored record, but facility is not storing the medication and is not listed on medication destruction record.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Administrator Cherry Agravante and facility staff Ramandeep Kaur signed report, copy of report left at facility