Beginning at 10:37AM, the LPA, along with Licensee 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. The following was observed:

Hardwired combination smoke and carbon monoxide detectors were tested at 12:51PM and were functional at the time of the visit. Fire extinguisher was observed to be fully charged and purchased on 10/24/2025.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 4 (four) total bedrooms for resident use; 2 (two) are shared rooms and two (2) are private rooms.

RESTROOMS: The LPA observed two (2) restrooms in the facility. One (1) is for resident use and one (1) is designated for staff use. Resident restroom was observed to be clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Water temperature was measured in the resident restroom at 10:45AM and measured at 137.5 degrees Fahrenheit.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Adjacent to the kitchen is a locked garage. The garage was observed and contained the laundry area, as well as emergency food supply and water, and storage.

Report 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.

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits were observed to be clear of hazards. Outdoor gate was observed to be functional, however, not self-closing or latching at the time of the visit. At this time, no residents have documented elopement or unsafe wandering behaviors. LPA advised Licensee to ensure the gate is self-closing and latching in the event any residents' needs change or residents are admitted that may have unsafe wandering or elopement behaviors.

RECORD REVIEW: Beginning at 10:54AM, 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. 5 (five) resident records reviewed were complete and contained all required documents. 5 (five) staff files reviewed were complete and contained all required documents.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, as required. Emergency drills are conducted quarterly, with the last drill documented on 10/30/2025.

MEDICATION REVIEW: Beginning at 12:29PM. medications for 2 (two) residents were observed. Both two (2) of two (2) residents' medications were observed to be maintained and administered in compliance with regulation.

INTERVIEWS: Throughout the visit, LPA interviewed two (2) staff and four (4) residents. No concerns were noted during interviews.

Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Licensee was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.