LPA and house manager toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

COMMON AREAS: The common area furniture's were observed to be in good condition. A sufficient supply of clean linen and towels were observed stored in the hallway cabinets. The facility maintained a temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and last purchased on 04/03/2026. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. The LPA observed the required postings in the common area and fireplace was observed adequately screened.

Continued on LIC 809-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.

BATHROOMS: There are two (2) bathrooms for residents’ use. They were observed to be clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured between 105 - 120 degrees Fahrenheit.

KITCHEN: Knives and sharp objects are stored inaccessible in a drawer to the left of the sink. No cleaning supplies were observed stored in the kitchen area. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. Dining area was observed to be clean, and furniture appeared to be in good condition.

GARAGE: There’s an attached garage. LPA observed garage to be locked and inaccessible to residents in care. LPA observed two (2) additional fridges and freezer to store extra perishable food. LPA also observed additional non-perishable supplies, canned goods, PPE, extra incontinent supplies, chemical and detergents as well as additional furniture and medical equipment for facility use. Laundry area was located in the garage.

OUTDOOR SPACE: All exits have functioning auditory devices and were operational at the time of the visit. The backyard has a covered outdoor area equipped with furniture including tables and chairs for residents’ use. The LPA observed two (2) self-latching gates with clear passageways clear of obstruction. The LPA observed a locked shed with gardening tools and medical equipment inaccessible to residents in care. No bodies of water were noted at the time of the visit.

Continued on LIC 809-C

RECORDS REVIEW: Five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, and consent forms. The following was observed: Resident #2 (R2) had an incomplete physician’s report. Technical Violation (TV) issued. Resident #3 (R3) had bed rails extending the entire length of the bed, however, the resident is not currently receiving hospice services. The facility has an approved waiver for two (2) hospice residents, however, at the time of the visit, three (3) residents were receiving hospice services. Recently admitted residents were missing required admission documentation (TV) Technical Violation issued. Residents who have resided for more than one year (Resident #4 [R4] and Resident #5 [R5]) did not have a complete and signed Needs and Service Plan. Four (4) Personnel records including the Administrator were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Per Administrator Certification Bureau (ACB) a renewal application on 4/4/2025 was deemed incomplete, and a new renewal application is required. Administrator’s certificate last expired on 04/30/2023 and current facility’s fees are due.

MEDICATION REVIEW: There is an office area next to the kitchen where medications are locked and stored inaccessible to residents in care. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are documented on the centrally stored medications and destruction record. During today’s visit LPA informed the house manager removing medication from their original packaging in advance of administration (pre-pouring) is not permitted. Technical Violation (TV) issued.

The LPA obtained the following documents at the time of visit: Personnel Report (LIC500), Client Roster (LIC9020), and a copy of the facility’s liability insurance.

Additionally, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. Emergency disaster drills are conducted quarterly, with the last drill conducted on 04/02/2026.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D) Administrator was informed that failure to correct the deficiencies may result in civil penalties. A $500 immediate civil penalty is assessed today. The Administrator, Ruth Grande was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e).

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.