The facility is licensed for a total capacity of six residents, including two ambulatory and four non-ambulatory residents, with a hospice waiver for four residents. At the time of the visit, the facility was operating at full capacity with six residents, and none were receiving hospice care.

LPA began by reviewing records, including six resident files and two staff files. Some resident files were missing complete physician’s reports. Staff files generally contained the required documentation; however, one staff member had a health screening on file but did not have documentation of a TB screening. The Administrator’s certificate is current and valid through November 28, 2026.

LPA then toured the facility with staff. The home consists of five resident bedrooms, including one shared room, three full bathrooms, a living room, kitchen, laundry room, attached garage, and a designated resting area for caregivers. Throughout the inspection, the facility was observed to be clean, organized, and free of hazards, with clear and unobstructed pathways. Smoke detectors and carbon monoxide detectors were operational in both common areas and bedrooms. The fire extinguisher in the kitchen was fully charged, and records indicated that the last disaster drill was conducted on March 3, 2026.

Resident bedrooms were properly furnished with appropriate beds, linens, and adequate storage space. Bathrooms were clean and in good condition, with working toilets and faucets, secure grab bars, and

(Annual Inspection continued on LIC809C)

• 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.

The kitchen was inspected and had an adequate supply of perishable and non-perishable food. However, LPA observed that the stove burners were not functioning and did not ignite. Sharps were secured in a kitchen drawer and under the sink. Cleaning supplies and other toxic substances were properly locked and stored in the kitchen, laundry room, and garage, making them inaccessible to residents. Emergency food and water supplies were observed in the garage. The first aid kit was complete and contained all required items.

The outdoor areas were also inspected and found to be safe and accessible. There was ample shaded seating for residents, and exit gates on both sides of the house were self-latching and operational. The facility provides activities based on residents’ preferences, needs, and abilities. Staff reported that residents participate in activities such as coloring, painting, walking, and exercising. During the visit, LPA observed residents watching television.

Medication storage and administration practices were reviewed. Medications were securely stored in a locked cabinet in the kitchen and were being administered according to physician orders.

LPA interviewed residents regarding their quality of care and spoke with staff about the services provided. Feedback indicated that residents’ needs were being met.

Based on observations and records reviewed during the inspection, deficiencies were identified and cited in accordance with Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator Tin Le by phone. Copies of LIC 809, LIC 809-C, LIC 858, LIC 859, LIC 9102TV, LIC 809D, and Appeal Rights were reviewed and provided to the facility. Additionally, a Legionnaires’ Disease Fact Sheet was given for informational and preventive purposes.