Beginning at approximately 01:50 PM, the LPA, along with S2 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 had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed secured cabinets which contained knives and other sharp objects, resident medications, facility files, and an incomplete first aid kit which was missing a first aid manual. LPA informed S2 that a complete first aid kit shall be maintained and be readily available and shall include a current edition of a first aid manual. S2 expressed understanding and agreed to obtain a current first aid manual for the facility. LPA observed the kitchen to contain adequate emergency food supplies. LPA observed a fire extinguisher mounted in the kitchen to be fully charged and purchased on 09/24/2025.

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 included the living room, hallway, and dining area. The living room was observed to be clean and in good repair. The living room contained adequate seating for resident use. LPA observed the living room to contain a television and activities for resident use. LPA observed a hallway closet which contained extra linens and care supplies. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contained a dining table with adequate seating for resident use. The facility’s fire and carbon monoxide alarms were tested at 03:04 PM and were functional at the time of the test.

BEDROOMS: There are four (4) bedrooms in the facility; two (2) are a dual occupancy rooms and two (2) are single occupancy rooms. LPA and S2 toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA observed bedroom #1’s closet doors to be in disrepair. LPA notified S2 who stated that a repairman was coming later today (04/09/2026) to perform repairs to the doors. LPA observed unsecured paints located in the closet of bedroom #2. LPA notified S2 who secured the items at the time of the visit.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) bathroom is designated as private resident bathroom, and one (1) bathroom is designated as a shared resident bathroom. Both resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. LPA observed the shared resident bathroom’s tub to be consistently leaking water from the faucet. LPA notified S2 who agreed to schedule a repairman to perform repairs to the tub. Grab bars were observed in all resident showers and near the shared resident toilet, all were properly secured.

CONTINUED ON LIC 809C.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 01/25/2026. The facility’s emergency disaster plan is up to date but contained inaccurate information on the storage location of emergency supplies. LPA notified S2 who agreed to complete an update to the facility’s emergency disaster plan. The emergency disaster plan and the infection control plan are reviewed/updated annually by the facility’s Administrator.

INTERVIEWS: LPA interviewed two (2) residents. Both residents interviewed stated that the staff treat them well and are attentive to their needs. Both residents had no concerns with the facility. One (1) staff interview was conducted with the assistance of S2 acting as a translator. The staff member interviewed was knowledgeable on the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, emergency disaster plan, and current liability insurance.

The facility Administrator was unable to come to the facility to sign this report but has designated S2 to sign on their behalf. This report was read to the Administrator via telephone call.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.