Facility Evaluation Report

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator, Matthew Magsambol Continual Administrator's Certification expires 04/08/2026. There are currently 6 residents who reside at this home and there is 0 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. 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. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA reviewed 3 staff files, 4 resident files, Plan of Operation, Infection Control Plan, and Emergency Disaster Plan.

LPA observed resident 1's bedroom door is broken. LPA observed Resident 2 does not have required annual updated assessment. Resident 2's as needed PRN medications are not logged correctly. Resident 2's admission agreement does not include basic rate charged for services. LPA observed the facilities yard does not have patio furniture or covered patio space. LPA observed the facilities hallways bathroom sink water temperature measures at 124 degrees. LPA observed cobwebs throughout the facility with spiders, and multiple smoke alarms chirping. The facility does not have an accurate record tracking resident monies.

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, Mathew Magsambol and copy of report left at facility