Facility Evaluation Report

At approximately 10:15, Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection visit. LPA was greeted by designee/caregiver Mary Ann Ordono. Administrator Charmaine Mendaros arrived shortly later. Facility is a Residential Care Facility for the Elderly that has a fire clearance approved for six non-ambulatory residents and one bedridden in rooms 1,2,4 and 5 only. Approved hospice waiver for 5 residents.

LPA toured the building and grounds which was found to be clean and at a comfortable temperature. LPA observed all walkways and exits to be unobstructed. All required postings were in a highly visible area. Fire extinguishers were charged and last inspected 2/14/2025. Fire alarms and carbon monoxide detector were tested and operational. Outdoor emergency exit clear from obstruction. Water temperature measured at 116.4 degrees F at faucets accessible to residents which is within the allowable range of 105 to 120 degrees F. Disaster drills are conducted quarterly with the last drill conducted on 10/01/2025.

All bedrooms were equipped with lighting, a night stand and chest of drawers. Resident bathroom lacked bath mat, grab bar was observed (Technical Advsory given). LPA observed plastic mat in shared resident room #2 to be lifted and have ripping, presenting a tripping hazard to resident (Technical Violation given).

LPA observed a Fire Clearance Violation as closet in shared room 1 and 2 to be occupied for live in staff. Mattress with bedding, personal items and camera was observed inside residents closet (Deficiency Cited, see 809D) **Immediate Civil Penalty assessed in the amount of $500 due to fire clearance violation. LPA had conversation about the importance and potential dangers of having an unapproved room. Mattress was removed during inspection.