The LPA and 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.

INTERVIEWS: Starting at 10:08 a.m. and throughout the visit one (1) staff and four (4) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit.

COMMON AREAS: This includes the family room, living room, and dining room. At the time of the visit, furniture in the common areas was observed to be in good condition. The walls in the living room and dining room were in disrepair with cracks, wilts and paint chipping. The LPA informed the Administrator that the walls must be repaired. The facility maintained a comfortable temperature. At 3:16 p.m., hardwire combination of smoke / carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 05/20/2025. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 10/11/2025 and are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened. Report Continued on LIC 809-C PAGE 2...

• 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.

There is a functioning telephone on the premises. The auditory alarms at the front door entrance and sliding door exit located in the family room were observed to be turned off the time of the visit, LPA advised the Administrator that they need to be functional at all times. Both alarms were turned on and functioned properly at the time of the visit.

BEDROOMS: There are five (5) total resident bedrooms in the facility; four (4) bedrooms are designated as private, single occupancy, resident rooms and one (1) is designated as a double occupancy, shared resident room. Four (4) out of five (5) resident rooms have exits to the exterior. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are two (2) total restrooms. Both restrooms are designated as a shared / common resident restrooms. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 110.1-118.6 degrees Fahrenheit, all within the required range. LPA observed storage space closets in hallway containing extra clean linens and towels for resident use.

KITCHEN: The LPA inspected the kitchen/food service area at 11:01 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 117.1 degrees Fahrenheit at 11:02 a.m. Cleaning supplies and other chemicals are kept under the sink and in the garage. At 11:02 a.m. LPA observed the lock on the under sink cabinet to be in disrepair, malfunctioned and not lock at the time of the visit leaving chemicals accessible to residents in care. At the time of the visit the Administrator moved the chemicals to the locked garage so they are inaccessible to residents in care.

LAUNDRY ROOM: LPA observed the locked laundry room adjacent to bedroom #5. Laundry room has a washer and dryer and locked cleaning supplies.

Report Continued on LIC 809-C PAGE 3...

GARAGE: LPA observed the attached facility garage, which was locked at the time of the visit. LPA observed emergency food and water, personal protection equipment (PPE) , incontinent supplies, and an extra refrigerator/freezer that was checked for proper labels and expiration dates. The facility’s floor plan provided to CCL did not indicate a staff room however during the physical plant tour LPA observed a locked staff room located in the garage. The Administrator stated that the room is permitted however CCL does not have any documentation or fire clearance for the staff room. The staff room is kept locked at all times and observed to be occupied by staff. LPA explained that fire clearance violations are a zero-tolerance violation and an immediate civil penalty in the amount of $500 will be assessed on today’s date (11/7/2025). LPA informed Administrator that failure to adhere to the requirements of their fire clearance may result in the assessment of additional civil penalties.

RECORDS: Resident Records were reviewed beginning at 11:23 a.m. Six (6) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Record review revealed that Resident #1 who was admitted on 09/22/2025 is missing documentation and their file is not complete including pre admission agreement, needs and service plan and signatures.

Personnel Records were reviewed beginning at 1:33 p.m. five (5) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard.

Report Continued on LIC 809-C PAGE 4...

MEDICATIONS: Medication review began at approximately 2:16 p.m. Medications are centrally stored and locked in a cabinet in the kitchen adjacent to the dining room. Medications for three (3) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review. LPA observed the first aid supplies to be complete, including a thermometer and a current version of a first aid manual.

DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster and LIC 9020A Resident roster. The Administrator emailed a copy of the Limited Liability insurance to the LPA during the visit.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty was issued in the amount of $500. Administrator was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.