Beginning at 10:25AM, the LPA along with Administrator toured, the facility to ensure there are no health and safety hazards and the facility is in compliance with regulation. The following was observed:

Fire extinguisher was observed to be fully charged and last serviced 08/22/2025. Hardwired combination smoke and carbon monoxide detectors were tested at 12:29PM and were functional at that time.

OUTDOOR SPACE: The back yard area is enclosed, with one gate that was observed to be self-closing and latching. Although the latch has a built-in lock, the LPA reminded the Administrator that the gate cannot be locked due to fire safety and fire clearance. The backyard contains a shaded seating area and appropriate outdoor furnishings. There are no bodies of water on the premises. The backyard contains access to a locked garage. LPA observed the garage to contain extra cleaning supplies, storage, and paper goods.

RESIDENT BEDROOMS/BATHROOMS: The facility consists of 6 (six) bedrooms; 1 (one) is designated for staff use and 5 (five) are resident rooms. All 5 (five) bedrooms are furnished for resident use, containing all required furnishings and a sufficient supply of linens. Resident #1 (R1) was observed to have full bed rails on their bed, however, R1 is not on hospice and does not have an exception on file for use of full bed rails. The staff room remains locked. There are 2 (two) restrooms in the facility. 1 (one) is a shared resident bathroom and the other is for private resident use. Both restrooms were observed to be clean and

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.

COMMON AREAS: The sitting area/television room, and dining area are furnished appropriately. Paint, windows, window coverings, and floors are in good repair. The LPA observed the required postings in the entry way. Auditory devices on all exits were operational. Common area was maintained at a comfortable temperature during the visit. The facility has a laundry closet located off the hallway leading to the garage, which contains an operational washing machine and dryer. Activity supplies were observed, including games, and a piano. Cameras were observed in the common areas. Administrator forwarded LPA an email dated 07/30/2025 regarding the use of cameras. LPA will review the request and follow up with Administrator as appropriate.

KITCHEN/FOOD SERVICE AREA: The facility has a sufficient supply of perishable and non-perishable foods, emergency food and water. Knives and sharp items were stored in a locked cabinet under the sink. Cleaning supplies and disinfectants were stored underneath the locked kitchen sink and in the locked cabinet above the washer. The facility has a sufficient supply of plates, cups, and utensils.

RECORD REVIEW: Beginning at 10:48AM, the LPA reviewed 5 (five) resident files for items including but not limited to: physician’s report, Admission Agreement, personal rights, and needs and service appraisal. All resident records reviewed contained all required documents. Beginning at 11:32AM, the LPA reviewed 4 (four) staff files for documents including but not limited to: health screening, TB test results, and trainings. 3 (three) of 4 (four) staff files reviewed did contain documentation of training, however, all were recently hired and did not contain proof of 40 hours initial training, however all transferred from other facilities where trainings were completed. Additionally, 2 (two) direct care staff did not have current first aid training. LPA provided additional information to the Administrator related to trainings.

MEDICATIONS: Medications were observed to be locked and stored in compliance with regulation. Beginning at 12:32PM, LPA reviewed medications for 2 (two) residents. During medication review, LPA noted that both residents have been prescribed PRN (as needed) medications, but do not have a PRN authorization form on file indicating whether the resident can determine their need for a PRN medication. Additional information related to medication administration and best practices were discussed with the

EMERGENCY DISASTER PLAN/INFECTION CONTROL PLAN: During today’s visit, LPA reviewed both the facility’s emergency disaster plan and infection control plan. The facility’s procedures as it relates to infection control are adequate. Both documents have been reviewed and updated annually as required. The facility’s last documented emergency disaster drill was a fire drill conducted on 07/21/2025.

INTERVIEWS: During today’s visit, the LPA interviewed 3 (three) staff. Residents were unable to be interviewed at this time.

Pursuant to Title 22 of the CA Code of Regulations, 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. A copy of the report and appeal rights were provided.