Beginning at 09:46 A.M. the LPA, along with Licensee/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. Please note: the facility is a 2-story house; the upstairs area is inaccessible to residents in care and is used for staff only, therefore was not observed. The following was observed in the downstairs area:

Hardwired combination smoke and carbon monoxide detectors were tested at 10:00 A.M. and were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 11/20/2024. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.

BEDROOMS: There are 5 (five) total bedrooms; 4 (four) are designated for private resident use and 1 (one) is a shared bedroom. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

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: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be inaccessible to residents in care. LPA observed a ring doorbell, administrator did not know that a waiver is required to have ring doorbell. LPA did not cite but advised the licensee to submit a waiver for the Ring doorbell due to the audio component, to update plan of operation and admission agreement. LPA observed surveillance cameras installed in the common areas of the facility as well along the exterior perimeter of the property.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. At 9:35 A.M. hot water was measured and measured at 114.5 degrees Fahrenheit.

GARAGE: Locked garage is located adjacent to the kitchen. Garage was observed and contained extra food, emergency food, cleaning supplies and storage, as well as laundry area.

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits and passageways were observed to be free of hazards. Facility has two total gates; both were observed to be self-closing and self-latching gate with clear passageways for emergency exit use. There were no bodies of water on the premises.

RECORD REVIEW: Began at 12:05 P.M., staff and resident records 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, and personal rights. LPA reviewed six (6) resident’s files. Records reviewed were complete and contained all required documentation. However, Resident’s #1 (R1’s) file included an updated physician’s report indicating that a chest X-ray was conducted to confirm no evidence of active tuberculosis (TB). Despite this, the TB test result was not available in the file. LPA reviewed six (6) staff records including the Administrator. A Guardian system check for criminal background clearance and association of staff was conducted during today’s visit. LPA reviewed the facility’s personnel report (LIC 500), dated on 06/01/2025, provided by the Administrator during today’s visit. Upon review, it was observed that Staff #1 (S1), who was present and was cleaning and providing assistance to residents in care, has an incomplete application in Guardian and as of today they are not yet associated or fingerprinted. During today’s visit Administrator instructed S1 to leave the facility immediately and not return until the fingerprinting and association process is finalized. Five (5) staff files reviewed did not have annual training. All other documentation were updated and complete as requested.

MEDICATION REVIEW: Medications are stored in a large, locked pantry. In there, LPA observed file cabinets, emergency food and water and first aid kits. Medication review began at 2:07 P.M. Medications for four (4) residents were observed. Medications reviewed were documented and labeled in accordance with regulation.

Continued on LIC 809-C

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

At the time of the complaint, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(e).

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