The facility’s fire clearance is approved for six (6) residents age 60 and over, including up to six (6) non-ambulatory residents, of whom one (1) may be bedridden. The facility also holds a hospice waiver for six (6) residents.

At the time of inspection, there were six (6) residents in care.

Facility Tour & Observations:

Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present.

Required “Oxygen in Use” signage was posted in visible locations throughout the facility in accordance with safety requirements.

Physical Plant

The facility is located in a residential neighborhood and is a single-story home consisting of five (5) resident bedrooms, three (3) bathrooms (one of which is designated as a guest bathroom), a living room, family room, kitchen, dining area, and a caregiver corridor near the kitchen and attached garage. An additional caregiver corridor is located near the resident restroom. All bedrooms observed contained the required furnishings, including a bed, mattress, linens, dresser, chair, and adequate lighting. Bathrooms were observed to be clean and equipped with required grab bars in the showers and near the toilets, as well as non-skid mats. Hot water temperatures measured 116.9°F in Restroom (1) (guest restroom), 109.9°F in Restroom (2) (resident restroom), and 114.3°F in the third bathroom. (continued on 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.

Food Service

Refrigerators and freezers were maintained at proper temperatures (refrigerators at a maximum of 40°F and freezers at 0°F) and contained a sufficient supply of food, including at least two (2) days of perishable food and seven (7) days of non-perishable food. Fresh produce, proteins, and dry goods were stocked. LPA observed that kitchen knives were locked in kitchen drawer.

Health-Related Services & Records

Five (5) resident files were reviewed. The files contained current required documentation including Admission Agreements, signed consents, Needs and Services Plans, Physician’s Reports documenting TB results and ambulatory status, and Resident Rights acknowledgments. However, LPA observed that Resident 1 (R1) and Resident 4 (R4) were missing physician’s orders authorizing the use of bed rails. A deficiency will be issued.

Four (4) residents’ medications were reviewed. Medications were observed to be centrally stored in a locked closet located near the dining and kitchen area. During the medication review, LPA observed that Resident 5 (R5) had several missed evening medications, as evidenced by the medication bubble pack. A deficiency will be issued.

Disaster Preparedness

Last fire/earthquake drill was conducted on March 3, 2026, with logs available. LIC 610D Emergency Disaster Plan was available and updated. Emergency supplies (water, food, flashlights, batteries, first aid) were observed. Infection Control Plan was updated.

Personnel Records & Training

Four (4) staff files were reviewed and included criminal record clearances, CPR/First Aid, required training and TB screenings. Administrator Certificate for Xiomara Valencia was valid through February 25, 2027.

Insurance

Liability insurance was in compliance with an expiration date of May 5, 2026.

An exit interview was conducted with the Administrator Xiomara Valencia. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights were provided.