At 10:06 AM, the LPA initiated a walk-through of the facility, accompanied by the caregiver.

LPA inspected the kitchen and found it clean, with no food preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet containing knives and sharp objects, and a locked cabinet under the sink with detergents and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted.

LPA inspected the dining area adjacent to the kitchen and found it clean. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. The indoor temperature reading of 72°F on a thermostat was observed in the hallway at the time of the visit.

LPA inspected the living room and observed it clean, with all furniture in good repair. There were sofa sets, chairs, tables, and a television in the living room. (2) residents were observed sitting in the living room watching TV.

LPA inspected the fire extinguisher mounted on the wall in the living room and found it fully charged, with the

Continued on LIC809-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.

LPA inspected the garage and found it clean. A washer, a dryer, a refrigerator and a freezer containing additional food supplies, storage racks shelves with non-perishable food items, incontinence supplies, file cabinets, suitcases and cabinets containing pillowcases, mattress pads, bedsheets, and towels were observed inside the garage.

LPA toured the backyard and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. No bodies of water were noted. LPA inspected (1) storage shed in the backyard and noted a Hoyer lift, wheelchairs, and mattresses stored.

LPA reviewed five (5) staff personnel records and five (5) resident records. The LPA observed that 5 of 5 residents had an Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 5 of 5 staff members were associated with the facility.

LPA observed locked centrally stored medication cabinet in the kitchen. Medications were organized separately for each resident. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete.

LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster (Fire and Earthquake) Drills were conducted every two months, with the most recent drill completed on 05/07/2025.

The following updated forms are requested to be submitted to CCLD by 05/22/2025:

1) LIC 500: Personnel Report 2) LIC 308: Designation of Facility Responsibility

3) Certificate of Liability Insurance 4) Administrator Certificate(s)

No deficiencies were cited during today's visit.

An exit interview was conducted with the caregiver. A copy of this report was left with the caregiver, Karen Marcela, whose signature on this form confirms receipt of the report.