Facility is licensed to serve (6) non-ambulatory residents over the age of 60, of which (4) may be bedridden residents in bedrooms 1 and 4. Facility has an approved waiver for (2) hospice residents.

At 11:15AM physical tour was conducted with the Administrator and LPA observed the following:

Required postings were observed by the entry area and throughout the home. The smoke/carbon monoxide detectors are hardwired and interconnected. At 11:25am smoke/carbon monoxide detectors were tested and observed to be functional. The fire extinguishers are located by the entry door and in the kitchen. Both fire extinguishers were serviced on 09/04/2025. Facility conducts quarterly Fire/Earthquake drills; the last Fire/Earthquake drill was conducted on 10/01/2025. The auditory alarms on all exit doors were functional at the time of the visit.

Common Areas: The living room and dining area appeared clean and were properly furnished. The living room has a television set and gaming cabinet. There is a non-operational fireplace in the living room, covered by a metal screen. The dining room is located next to the kitchen and is furnished with a table and chairs, appropriate for number of residents.

Continued on 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.

Bathrooms: The facility has one (1) bathroom, located between bedrooms #3 and #4. The bathroom contained paper towels and liquid soap, 2 lided trash cans, grab bars and a non-skid mat. Hot water temperature measured at 113.7°F.

Bedrooms: The facility has four (4) bedrooms. Bedridden designated rooms are #1 and #4, each with an emergency exit. Bedrooms #1 and #4 are shared and bedrooms #3 and #4 are private. All bedrooms were clean and odorless and furniture was in good repair.

Surrounding Grounds: LPA toured the back yard and observed one set up patio furniture at the side of the yard and another set under a covered patio; there is also furniture at the front yard. Garage is accessed from the front and is used as a storage and also to park cars. Emergency water and food supplies were stored in garage cabinets and in the refrigerator in garage. There are two tall water fountains, one in the backyard and one at the front yard but there is no pool. Facility has exit doors in bedrooms #1, #4, in the kitchen and by the office area but the front door is used as the main emergency exit. All passageways were observed to be clean and free of obstructions.

Medications: There is a locked refrigerator in the kitchen, to store medications. There is a locked cabinet located in the kitchen for storing medications. LPA counted medications for 6 out of 6 residents and compared them to physician medication orders for accuracy of administration. LPA observed a complete first aid kit and first aid manual inside the front entry cabinet.

Resident/Staff Files: All confidential staff and resident files are maintained in a locked cabinet, in the office area. LPA reviewed files for all six (6) residents for required documents. LPA also conducted a file review of staff records to ensure forms and training are up to date and in compliance with licensing requirements.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies were observed during the visit. Exit Interview conducted / A Copy of the Report Issued to the Administrator.