At approximately 1:45PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 02:05PM, LPA and Licensee toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Staff were in the process of cleaning up kitchen at the time of this inspection. Toxins are stored in a locked under the sink and housekeeping closet in the laundry room. Water temperature measured 109.6 degrees F and 107.4 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. There is a covered seating area in the backyard with outdoor space for activities.

Fire Extinguishers found to be last charged on 05/02/2025 at the time of visit. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in a cabinet cabinet next to the dining room.

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.

At approximately 2:35PM, LPA reviewed 3 resident records and found 3 of 3 residents have current care plans, signed admission agreements, and physician's report on file. Medication records are thorough and contained physician's orders for each resident.

At approximately 2:55PM, LPA reviewed 2 staff records. 2 of 2 records did contain documentation of completed training records as required. Evidence of current first aid and CPR training were current. LPA was presented with proof of current CPR & 1st Aid certification for the whole staff. Administrator Certificate is for Jose Arsenio Angeles #6073061740 expires 06/17/2026.

LPA reviewed P&I, medications, and medication records which are maintained and stored in compliance with regulation. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 09/02/2025.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 10/25/2025:

- LIC 308 Designated

- LIC 500 Personnel Summary

- LIC 610 Emergency Disaster Plan (If changed)

- LIC 9020 Register of Facility Client’s/Resident’s

- Copy/Proof of Updated Certificate of Liability Insurance

No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.

Exit interview conducted. Copy of report provided to Administrator. Signature on form confirms receipt of documents.