Beginning at 03:06PM, 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:

COMMON AREAS: Living room and dining room furniture was observed to be in good condition. There is a screened fireplace in the living room. The facility maintained a comfortable temperature throughout the visit. Smoke detector(s) and carbon monoxide detector were tested at 03:31PM and were operational at the time of the visit. The fire extinguishers were observed to be fully charged and last serviced 05/14/2024. All exits have auditory devices. The LPA observed required postings throughout the common space.

KITCHEN: Knives and cleaning supplies are locked in an under the sink cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

GARAGE AND GROUNDS: The garage is attached to the house and locked at all times. The laundry room is located in the main hallway and is kept locked and inaccessible. Cleaning supplies and disinfectants are kept in locked cabinets in the laundry room. There is one (1) additional refrigerator in the garage with perishable items in good condition. Facility has an adequate amount of emergency food and emergency water. There is patio furniture including a table, umbrella, and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. There were no bodies of water noted. Garage contains a staff room, which Administrator stated is permitted.

Report Continued on LIC 809-C

RESTROOMS: The two resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in the common hallway restroom at 146.4 degrees Fahrenheit at 03:11PM.

RECORDS: Records review began at 02:35PM; four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. During the resident file review, it was revealed that on 11/14/2024, Resident #1 (R1) was admitted to the facility. R1 did not contain a completed file, with only an Admission Agreement, Consent Forms, Personal Rights, and pre-Admission Appraisal. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All 3 (three) of 3 (three) staff files were complete at this time.

MEDICATIONS: Medications review began at 03:40PM. The 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. Administrator was advised to obtain PRN (as needed) authorization forms for all residents prescribed PRN medications.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's emergency disaster plan and infection control plan. Both documents were observed to be complete and updated annually as required. The facility conducts emergency drills every 2 months, with the last drill documented in October 2024.

INTERVIEWS: During today's visit, LPA interviewed staff and residents throughout. No concerns were identified during interviews.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were issued.