LPA and Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: LPA toured the kitchen at 11:35AM with staff. Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: The facility has six (6) single-occupancy resident rooms and one (1) staff room, all of which were furnished appropriately; beds had clean linens and rooms had sufficient lighting. All direct exits were clear, and no obstructions were noted. Auditory exit alarms in all bedrooms were functional and operating. Staff room was kept locked and inaccessible during the visit.

RESTROOMS: The facility has seven (7) restrooms. Six (6) out of six (6) resident bedrooms have an attached restroom and there is one (1) common restroom in the hallway for staff and visitor use. LPA observed bathrooms to be clean, sanitary, and in operating condition with slip-resistant surfaces and grab bars. Hot water temperatures were measured in resident bathrooms and were between 109.2-114.1 degrees F, which is within the required range.

Report continued on LIC 809-C.

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for resident use. There is a side gate for resident use and is single-latched. No bodies of water noted.

RECORD REVIEW: Beginning at 12:05PM, LPA reviewed five (5) out of five (5) resident files and three (3) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, and staff training. All resident and personnel files were in order.

MEDICATION REVIEW: At 01:05PM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in a cabinet in the kitchen area. At 01:45PM, LPA observed Resident #1 (R1)’s Levothyroxine 75mg medication with the label stating “Take 1 tablet by mouth daily…5 days per week. Two days per week take half tablet.” However, upon interview and medication review, it was observed that staff administer the medication once daily except for Sundays and not as instructed on the prescription label. Administrator stated that there is no written order from the prescribing physician or the pharmacy; LPA explained that a written order is needed when administration instructions are different from the prescription label. All other medications, including PRNs, were observed to be properly documented on the centrally stored medications and destruction record and were in compliance with regulation, state, and federal law.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency drills are conducted quarterly as is required, with the last drill conducted on 09/03/2025.

Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiency may result in civil penalties.

Exit interview conducted, report issued, and appeal rights provided.