Beginning at 10:05 AM, the LPA, along with S1 toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a properly secured drawer to contain knives and other sharp objects. LPA observed a secure under-sink cabinet to contain cleaning chemicals. A secured cabinet was observed to contain resident medications and facility files. LPA observed a wall mounted fire extinguisher to be fully charged and purchased on 04/11/2025.

BEDROOMS: There are four (4) bedrooms in the facility; three (3) are designated for resident use and one (1) is designated as a staff room. LPA and S1 toured all four (4) bedrooms in the facility. The staff bedroom was observed to be locked and inaccessible to clients in care. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #3 contained an additional closet that contained the facility’s adequate emergency food supply.

Continued on LIC 809C.

• 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.

COMMON AREAS: This includes the living room and dining room. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains an appropriately screened fireplace, a television, and board games for resident use. Smoke detectors, fire doors, and carbon monoxide detectors were tested at 10:59 AM and were functional at the time of the visit. The dining room was observed to be clean and contained adequate seating for resident use.

OUTDOOR SPACE/GARAGE: The facility has one (1) emergency exit gate located at the front entrance to the property; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. The garage was observed to be secured and contained an extra refrigerator, a washer and dryer, cleaning chemicals, and extra care supplies. The garage was observed to contain adequate emergency water supplies.

RECORD REVIEW: Record review began at 11:03 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Three (3) staff files were reviewed. All staff files contained the required documentation and trainings. Five (5) resident files were reviewed. All resident files reviewed contained all required documentation and signatures. No deficiencies were observed during record review.

MEDICATION REVIEW: Medication review began at 12:22 PM. Medications for three (3) residents were observed. Resident #1 (R1) was observed to have a bottle of multivitamins stored with their medication. LPA reviewed R1’s file and did not observe a prescription for the multivitamin. Additionally, the multivitamin was not logged on R1’s Centrally stored medication and destruction record sheet (CSMDR). LPA informed the Administrator of the discrepancy. The Administrator informed LPA that the medication was given at R1’s request. The Administrator agreed to obtain a doctor’s order for the multivitamin. S1 updated R1's CSMDR to include the multivitamin at the time of the visit. Report Continued on LIC 809-C.

INTERVIEWS: LPA interviewed one (1) staff and one (1) resident. The resident interviewed stated that the food was of good quality and is provided in sufficient amounts. The resident stated that staff treat them well and are attentive to their needs. The resident interviewed had no concerns with the facility. The staff member interviewed was knowledgeable on their role and responsibilities, the resident rights, the different forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s updated LIC500, resident roster, and liability insurance.

Pursuant to Title 22 of the CA Code of Regulations the following deficiency was cited (refer to LIC 809-D).

The Administrator had to leave the facility during today's inspection but has designated S1 to sign this report on their behalf. This report was read to the Administrator via telephone call. Exit interview was conducted. A copy of the report, and appeal rights were provided.