Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 2
Nov 1, 2024
Visit Reason
An unannounced Required - 1 Year inspection was conducted to ensure compliance with Title 22 Regulations and health and safety standards at the facility.
Findings
The facility was generally found to be in compliance with regulations, with clean and safe physical plant areas, proper medication storage, and complete resident files. However, two deficiencies were cited: one for hot water temperature exceeding allowed limits in a resident restroom, and another for two staff members missing their annual required training.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Hot water temperature in one resident restroom measured at 124.2°F, exceeding the allowed maximum of 120°F, posing an immediate health and safety risk. | Type A |
| Two out of five staff members did not have documented annual required training, posing a potential health and safety risk. | Type B |
Report Facts
Staff missing annual training: 2
Resident bedrooms: 5
Staff bedrooms: 1
Hot water temperature: 124.2
Inspection duration hours: 6.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ivy Sudjati | Administrator | Facility administrator who arrived during the inspection and corrected medication prescription numbers. |
| Allan Santos | House Manager | Met with Licensing Program Analyst and toured the facility during the inspection. |
| Esther Cortez | Licensing Program Analyst | Conducted the unannounced Required - 1 Year inspection. |
| Kasandra Lopez | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 2
Oct 25, 2023
Visit Reason
An unannounced Required - 1 Year inspection was conducted to ensure compliance with Title 22 Regulations and to check for health and safety hazards.
Findings
The facility was generally in compliance with regulations, but two deficiencies were noted: the fireplace lacked an adequate screen, and the hot water temperature exceeded the allowed range.
Deficiencies (2)
| Description |
|---|
| Fireplace lacked an adequate screen, posing a potential health, safety, or personal rights risk to persons in care. |
| Hot water temperature readings exceeded the allowed range of 105°F - 120°F in two water heaters, posing a potential health, safety, or personal rights risk to persons in care. |
Report Facts
Deficiencies cited: 2
Water temperature reading: 135.1
Water temperature reading: 140.2
Capacity: 6
Census: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ivy Sudjati | Administrator | Met with Licensing Program Analyst during inspection and named in plan of correction |
| Teresa Camara | Licensing Program Analyst | Conducted the inspection and authored the report |
| Desaree Perera | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 1
Oct 26, 2022
Visit Reason
The inspection was a required 1-year unannounced infection control annual visit to the facility conducted by the Licensing Program Analyst.
Findings
The facility demonstrated compliance with infection control policies including screening, PPE use, isolation procedures, and staff training. However, one deficiency was cited related to a staff member working without prior criminal record clearance, which posed an immediate health and safety risk. The deficiency was corrected during the visit and a civil penalty was assessed.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| One facility staff was not associated to work in the facility prior to working, posing an immediate health and safety risk to residents. | Type A |
Report Facts
Civil Penalty: 500
Capacity: 6
Census: 6
Number of single rooms: 6
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Diego Cortez | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection. |
| Ivy Sudjati | Administrator | Facility Administrator responsible for infection control and corrective actions. |
| Allan Santos | House Manager | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 0
May 19, 2021
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 05/18/2021 regarding personal rights at the facility.
Findings
The investigation found that the resident in question was not currently residing at the facility, and therefore the complaint allegations were deemed unfounded with no basis.
Complaint Details
Complaint was related to personal rights. The complaint was investigated and found to be unfounded as the resident was not a current resident at the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation visit and resident record review. |
| Zabel Chochian | Licensing Program Analyst | Assisted in conducting the complaint investigation visit and facility tour. |
| Ivy Sudjati | Administrator | Met with investigators during the visit and exit interview. |
| Allan Santos | Caregiver | Accompanied investigators during the facility tour. |
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