Beginning at 11:00 A.M., the LPA, along with 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. The following was observed:

Hardwired combination smoke and carbon monoxide detectors were tested at 12:45 P.M. and were functional at the time of the visit. Fire extinguisher was observed to be fully charged and purchased on 11/06/2025. This facility doesn’t have a designated staff room and provides care on a 24-hours basis. LPA explained to the administrator that the use of surveillance cameras or baby monitors does not substitute for awake or on-duty staff during nighttime hours.

BEDROOMS: The facility consists of six (6) bedrooms. Each bedroom has its own bathroom; however, bathroom located in Room #6 will be shared visitors. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. During the inspection, LPA observed that the single ambulatory-designated room (room #6) was occupied by Resident #1(R1), who is currently non-ambulatory.

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 SPACES: These include the Family Room, Living Room and Dining Room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The LPA observed the required postings in the common area. The facility has a fireplace in the family room. At the time of the visit, LPA observed the fireplace to be properly screened. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a temperature of 72 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed two working phones available for residents use whenever needed. Facility is equipped with two fire doors to enhance safety and prevent the spread of fire.

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. LPA conducted a review of expiration dates on product labels. At 12:24 P.M. hot water was measured at 110.7 degrees Fahrenheit.

OUTDOOR SPACE: Garden and yard are easily accessible to residents, and they are sufficient in size, comfortable and appropriately equipped for outdoor use. There was a shaded area with proper furniture for outdoor use. LPA observed two (2) self-closing and latching side gates. LPA observed a non-working creek on the property. At the time of the visit, LPA did not observe water running through the creek. Also, LPA observed an operational water fountain located at the front entrance of the facility. The water fountain was functioning properly at the time of the inspection, and no issues were noted. Additionally, LPA observed video cameras facing the outside of the property.

Continued on LIC 809-C

GARAGE: Adjacent to the laundry area is a garage. LPA observed a recently constructed bathroom and two bedrooms. One bedroom contained one queen-size bed, and the second bedroom contained two twin-size beds. The administrator was unable to provide documentation showing that required city permits and/or Fire Clearance were obtained prior to the construction of the rooms and bathroom. LPA notified the administrator that no individual is permitted to sleep in or occupy the garage area until required permits and fire clearance have been obtain and approved. LPA did not check hot water temperature in the staff restroom.

RECORD REVIEW: Starting at 1:05 PM Staff records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, CPR and fingerprint clearance. Five (5) staff files reviewed were complete and contained all required documents.

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 emergency disaster plan are adequate, complete, and updated annually, as required. Emergency drills are conducted quarterly, with the last drill documented on 12/13/2025. During the physical plant tour, LPA observed a bus parked on the property. The administrator stated that the vehicle was purchased to transport residents and staff in the event of an evacuation. LPA requested current vehicle registration and observed that registration status was listed as Planned Non-Operation. LPA explained that the vehicle may not be operated or used for transportation until valid registration is issued. The administration stated that the facility has other vehicles with valid registration that are available and ready for use in the event of an emergency. Technical Violation (TV) issued.

Continued on LIC 809-C

Due to time constraints LPA will return at a later date to conduct medication audit and review resident records.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. An immediate civil penalty of $500 is assessed, due to a violation of fire clearance.

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