Facility Evaluation Report

On 9/11/2025, Licensing Program Analyst Arvin Villanueva (LPA) arrived unannounced at this facility to conduct their annual inspection visit. LPA met with staff on duty, Dave Valentine (S1) and stated the purpose of the visit. The designated facility manager, Bulou Matamadua (S2), was notified and arrived later during the visit.

Overview : Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents, 4 of which may be non-ambulatory. Facility has a hospice waiver for 3 residents. Bedrooms #1-3 were approved for non-ambulatory use. Bedroom #4 is for ambulatory use only.

Initial Observation: Upon arrival LPA was greeted by S1, who informed LPA that there are currently 4 residents present at this time with one staff on duty. One of the residents is currently out. LPA also observed an outside agency staff present but left shortly after. While LPA was setting up for the inspection, LPA observed S1 placed a door knob cover with a combination lock. Per S1, he placed the door knob cover because one resident has a behavior of eloping. Room temperature was at 69 degrees Fahrenheit.

Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA inspected 3 of 4 resident bedrooms and 2 of 2 bathrooms. LPA measured the hot water temperature in the 1 of 2 bathrooms (hallway) to be at 111 degrees Fahrenheit. Both resident bathrooms were observed to be in good repair at this time. LPA inspected the closet in the hallway and observed a cleaner (Fabuluso brand) on the shelf. This closet was unlocked and accessible to residents in care. Fire extinguisher was observed in the living room and was last inspected on 9/4/24.