COMMON AREAS: This includes the family room, den, and dining room. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. Hardwired combination carbon monoxide and smoke detectors and fire door are connected to the facility's Nest system, which records daily functionality of the systems. At 11:52 a.m. a test was conducted and all systems were functional at the time of the visit. The fire extinguisher was observed and fully charged on 02/28/2025. The emergency exiting plans/sketch are posted. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 08/13/2025 and are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened, covered and is non-functional. There is a functioning telephone on the premises. Auditory alarms at the entrances and exits were observed and functional at the time of the visit. LPA observed surveillance cameras installed in the common areas of the facility. The Administrator stated that the cameras are non-functional at the time however they may be used at a later time. LPA advised Manager and Administrator that if at any time the cameras become functional that none of them can be equipped with audio capability.

Report Continued on LIC 809-C PAGE 2...

• 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.

INTERVIEWS: Starting at 10: 08 a.m. and throughout the visit one (1) staff, one (1) resident, and one (1) visitor interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident and visitor interview revealed that no concerns were noted or voiced at the time of the visit.

BEDROOMS: There are six (6) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident rooms and one (1) staff rooms. The staff room is kept locked at all times and observed to be occupied by staff. Two (2) out of six (6) resident rooms have exits to the exterior. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are two (2) total restrooms. One (1) is designated as a shared / common resident restroom, One (1) is designated as a staff / guest restroom. Resident restroom was observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restroom. The restroom was sufficiently stocked with supplies and paper towels. The hot water temperature was measured in the resident restroom and measured at 110.2 degrees Fahrenheit, within the required range. LPA observed storage space closets in hallway containing extra clean linens and towels for resident use. LPA observed the staff /guest restroom sink to not drain properly / smoothly. LPA was advised by the Manager that they have a plumber scheduled and the repairs should be done within the next week as the pipe needs to be replaced in order for it to drain properly / smoothly, however the shower, toilet and sink are still functional.

KITCHEN: The LPA inspected the kitchen/food service area at 10: 35 a.m. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 10:42 a.m. LPA observed three (3) condiments in the refrigerator to be expired. Ketchup, celery paste, and lime juice all to be expired in 2023 -2024. In the pantry LPA observed five (5) cans ranging from soup (x3), beans (x2), vegetables (x1) to be expired in 2023-2024. LPA advised the Manager of the potential health and safety risk to residents in care. At the time of the visit the Manager discarded all the expired food items. The kitchen faucet was measured for hot water temperature, and it measured 112.3 degrees Fahrenheit at 10:39 a.m. Cleaning supplies and other chemicals are kept locked under the sink inaccessible to residents in care. Report Continued on LIC 809-C PAGE 3...

DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster, LIC 9020A Resident roster and a copy of the current Limited Liability insurance.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.