Beginning at 11:20 A.M., the LPA, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This facility doesn’t have a staff room; facility will provide 24/7 care. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The following was observed:

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for residents’ use. All exits and passageways were observed to be free of hazards. There were no bodies of water noted. Facility has two total gates; both were observed to be self-latching and closing with clear passageways for emergency exit use.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives, staff and resident files and medication were observed to be locked inside kitchen cabinets at the time of the visit. At 11:41 A.M. hot water measured at 136.9 degrees Fahrenheit. During today’s visit, the licensee adjusted the thermostats to bring water temperature within the required range.

Continued on LIC 809

• 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.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be inaccessible to residents in care. The facility maintained a comfortable temperature of 73 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. Individual smoke detectors were tested at 11:46 A.M. and carbon monoxide detector were tested at 11:48 A.M. All alarms were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 08/12/2025.

BEDROOMS: There are 5 (five) total bedrooms; 1 (one) of which is a shared resident room, 4 (four) are private resident rooms. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: The LPA observed 3 (three) restrooms in the facility; 1 (one) is for shared use and 2 (two) are designated for private resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Starting at 11:27 A.M., LPA measured hot water temperature in all restrooms, which were found to be above the required range of 105-120 degrees Fahrenheit. During today’s visit, the licensee adjusted the thermostats to bring water temperature within the required range.

RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Four (4) resident records reviewed were complete and contained all required documents. LPA reviewed medical assessments for Resident #1 and #2 indicating no capacity for self-care. During today’s visit, both residents were observed self-feeding.

Continued on LIC 809-C

MEDICATION REVIEW: Medications for four (4) residents were observed. Medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

EMERGENCY DISASTER PLAN/INFECTION CONTROL PLAN: LPA reviewed the facility emergency disaster plan and infection control plan, both of which were complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill documented on 10/02/2025.

During today's visit, LPA gathered the following items: Personnel Record (LIC500), Facility Roster (LIC9020A) and a copy of the facility's liability insurance.

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.

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