At 10:23 A.M. LPA conducted a physical plant tour inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Fire extinguishers are fully charged and last serviced 2/15/2026. The smoke detectors and carbon monoxide detectors are combined units; at 10:28 A.M they were tested and functioned properly. The facility has a fire door in the hallway which also functioned properly. The following was noted:

Bedrooms: There are 6 (six) total bedrooms in the facility; 4 (four) are designated for private resident use and 1 (one) is a shared room. All residents’ bedrooms were inspected and contained appropriate furnishings and linens. The facility also contains a staff room, which was observed to be inaccessible to residents in care. LPA observed that Resident #1’s (R1’s) bed was equipped with full bed rails, The administrator stated that R1 was recently discharged from hospice care and that the facility was awaiting removal of the hospital bed by the hospice agency. During today’s visit, care staff removed the full bed rails. Technical Violation (TV) was issued.

Continued from 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.

Common Areas: These included the dining area and living room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a designated telephone available for residents’ use. There are nightlights in all common hallways/rooms providing ample lighting to common bathrooms. A fireplace, which was properly screened, was observed in the living room. LPA observed all required postings on the wall in the main hallway/entryway. Additionally, LPA observed a complete first aid kit, PPE supplies such as gloves and mask and extra linens inside hallway cabinets. The facility maintained a temperature of 71 degrees. All facility exit doors contain functional audible alarms.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of non-perishable food at the facility; properly stored. Knives and sharp objects are stored locked inside a locked kitchen drawer. At 10:38 A.M. hot water measured 134.6 degrees Fahrenheit. LPA did not observe a hot water warning sign during the visit. The administrator adjusted the water temperature during the visit. Resident files and staff files were observed to be stored inside locked kitchen cabinet. The facility has a sufficient supply of perishable and non-perishable food and water. LPA conducted a review of expiration dates on product labels.

Continue on LIC 809-C

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises at the time of the visit. All passageways and exits were observed to be clear and free of hazards. Facility has two total side gates; both were observed to be self-closing and self-latching with clear passageways for emergency exit use. Facility provides sufficient space to accommodate both indoor and outdoor activities.

Garage: The facility garage is attached to the home; however, it has a separate locked entry, and it remains locked and inaccessible to the residents in care. Garage was observed to contain emergency water and food supplies, an extra fridge, as well as ample storage areas.

RECORD REVIEW: Between 11:35 A.M. and 12:54 P.M. LPA conducted a file review of resident and staff records. Six (6) resident and four (4) staff files 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, consent forms, and personal rights. All records were complete and current.

MEDICATION REVIEW: Medications are securely stored in a locked cabinet located in the kitchen. At 1:13 P.M. LPA reviewed medications for all six (6) residents. All medications observed were labeled, stored, and properly documented at the time of the visit.

Continued on LIC 809-C

During today’s visit LPA obtained a copy of the facility’s Personnel report (LIC 500), resident roster, and 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 9099-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.