Hennelly House.

On 04/14/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with staff Talica Matainisiga and explained the purpose of today's visit. During today's visit there are 5 residents in care and 3 staff present. This is a single level facility and is licensed to serve 6 residents all of whom may be non-ambulatory. Facility has a hospice waiver on file for 4 residents. There are 2 residents on hospice during today's visit. This is a single level facility. The physical plant is toured inside and outside to ensure the safety of the residents. During today's visit LPA observed 4 of the 5 residents. Two are sleeping in bed, one is awake watching TV in their room, and another is receiving home health care. LPA observed the facility kitchen which is located adjacent to the dining room. Knives are stored within the kitchen in a drawer adjacent to the sink. Medication cabinet is observed as lockable adjacent and above the counter to the sink. Although both have locks, both locks are not operable at this time. Perishable and non-perishable food items are observed as in place in the refrigerator in the kitchen. Additional refrigerator is observed to contain additional food items in the garage. Resident medications are in place and current. The first aid kit is maintained and is complete with required items. LPA observed fire alarm bells throughout the hallway where residents reside, fire extinguishers through out the facility are observed with inspection dates of 05/20/2025, smoke detector/carbon monoxide detectors are in place through out resident rooms and main hallway, and central heating in the facility as in place. Continued on next page. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 2 - LIC809 PPE is in place according to staff. Laundry room is also observed and is full operational and being used on this day. Chemicals and cleaning supplies are stored beneath kitchen sink and in the garage areas. Both areas are lockable. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Resident rooms are observed and all contained the required furniture as outlined in regulations. Water temperature is tested at 110F in common bathroom in main hallway and in 2 resident rooms. LPA asked about emergency drills being conducted, and was informed a recent drill has not been conducted, and there is no record to show. But in speaking with staff, they are knowledgeable of where to go and how to egress in case of an emergency. This poses a potential health and safety risk to staff and residents. 5 of 5 resident files are reviewed and 3 staff files are reviewed. LPA cannot confirm valid administrator certificates at time of this visit as the administrator certificate on file had expired on 07/26/2019. This item can pose a potential health and safety risk to residents in care. Resident files are reviewed and showed that R4 and R5 do not have documentation of annual doctor visit. Residents R1, R4 and R5 have a diagnosis of dementia and do not have current physicians report or medical assessments done within one year. This poses an immediate health and safety risk to resident's in care. 3 of staff files reviewed showed that all 3 do not have current first aid cards in place and 1 of 3 have current training. This poses a potential health and safety risk to residents in care. The following updated forms are being requested to be received by 04/22/2026 : • LIC610D Emergency Disaster Plan • LIC 308 Designation of Administrative Responsibility • LIC 500 Personnel Report • Updated administrator certificate • LIC9020 Client Roster • Certificate of Liability Insurance Per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies are cite on the following LIC809D pages. Report reviewed with staff and a copy is provided on this day.

On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with co-administrator/staff Kesa Vodonaivalu and explained the purpose of today's visit. LPA asked about the the listed administrator, Suzi Stefanac, and she indicated she is not present on this day but visits the facility multiple times a week. LPA was allowed entry to the facility. This is a single level facility and is licensed to serve 6 residents all of whom may be non-ambulatory. Facility has a hospice waiver on file for 4 residents. There are no residents on hospice during today's visit according to Kesa. Annual Fees are current. The physical plant is toured inside and outside to ensure the safety of the residents. During today's visit LPA observed 3 of the 4 residents, one of which was still sleeping in bed, and one is at the main dining table having breakfast. LPA observed the facility kitchen which is located adjacent to the dining room. Knives are stored within the kitchen in a drawer adjacent to the sink. Medication cabinet is observed as lockable adjacent and above the counter to the sink. It is unlocked at time of inspection due to staff distributing medications as observed by LPA. Perishable and non-perishable food items are observed as in place in the refrigerator in the kitchen. Additional refrigerator is observed to contain additional food items in the garage. Resident medications are in place and current. The first aid kit is maintained and is complete with required items. Continued on LIC809C... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 2 - LIC809 LPA observed fire alarm bells throughout the hallway where residents reside,fire extinguishers through out the facility are observed with inspection dates of 10/04/2023, smoke detector/carbon monoxide detectors are in place through out resident rooms and main hallway, and central heating in the facility as in place. PPE is observed in the garage. Laundry room is also observed and is full operational and being used on this day. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Resident rooms were observed and all contained the required furniture as outlined in regulations. Water temperature is tested at 108F in common bathroom in main hallway. The facility does not handle resident money. Current administrator certificate for Suzi Stefanac is current expiring on 07/15/2024. 2 of 4 resident files are reviewed and 3 staff files are reviewed. LPA cannot confirm valid administrator certificates at time of this visit as the administrator certificate on file had expired on 07/26/2019. This item can pose a potential health and safety risk to residents in care. Resident files reviewed showed that R1 and R2 have a diagnosis of dementia and do not have current physicians report or medical assessments done within one year. This can pose an immediate health and safety risk to resident's in care. The following updated forms are being requested to be received by 04/26/2024 : • LIC610D Emergency Disaster Plan • LIC 308 Designation of Administrative Responsibility • LIC 500 Personnel Report • Updated administrator certificate • LIC9020 Client Roster • Certificate of Liability Insurance Per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies are cite on the following LIC809D pages. Report reviewed with Kesa Vodonaivalu.