Overview: Facility is a one-story house located in a residential neighborhood. Facility is licensed to serve up to 4 elderly residents, up to 4 may be non-ambulatory. Facility does not have a hospice waiver. Facility does not have clearance for bedridden residents.

Physical Inspection: Areas inspected include, but not limited to, the kitchen, dining, resident units/bedrooms, resident bathrooms, common areas and outdoor areas.

LPA inspected 4 of 4 bedrooms. 2 of the bedrooms have exits. Per fire clearance, the doors for these two rooms need to remain unlocked for emergency exits. 2 bathrooms were inspected. Hot water temperature ranged from was measured at 114 degrees Fahrenheit. Hallway temperature was between was maintained at 72 degrees Fahrenheit.

Fire extinguishers were observed in the kitchen and was last inspected on 10/15/2025. Smoke and carbon monoxide detectors were observed throughout. During the testing of the detectors, the fire door automatically closed. LPA observed centrally stored medications, toxins, sharp objects and other dangerous items were kept locked and inaccessible to residents in care.

In the kitchen area, LPA observed at least seven-day non-perishable and two-day perishable food supplies. Pantry was observed to be fully stocked with non-perishable food items. Kitchen refrigerator and freezer were maintained at regulatory temperature at 40 degrees Fahrenheit and 0 degrees Fahrenheit. The additional freezer in the dining area needs a thermometer.

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• 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.

Record Reviews: LPA reviewed 5 staff files, 4 resident files, and facility records.

Review of resident files, including but not limited to, review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. LPA reviewed 2 of 4 resident medications. Facility manages 2 resident cash. Licensee counted 2 of 4 residents’ cash with LPA present. LPA reviewed current Surety Bond. Advisory was provided to reassess ambulatory status for 3 of 4 residents by their physicians.

Review staff files included, but not limited, background clearance, First Aid/CPR certificate, Health Screen, Initial Training. Records of dementia training were not available for review during this visit. Per licensee, she conducted the training but has not completed the certificates for her staff. Per review of Guardian and LIS, one of the staff on duty (S2) was not associated to this facility. S2’s employment date was 1/27/2026. Advisory was provided to complete LIC508 for each staff.

Review of fire drill/disaster drill records: facility conducts monthly drills and last drill was conducted on 1/15/26.

Documents Requested: LPA obtained a copy of current Surety Bond LIC500, LIC308 during this visit. LPA requested a copy of updated Liability Insurance Certificate to be emailed at arvin.villanueva@dss.ca.gov

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited and immediate civil penalties were assess in the amount of $500. Advisories were provided.

Exit interview was conducted. A copy of the report was provided upon exit.

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