At 11:07AM, the LPA along with staff 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.

KITCHEN: LPA inspected the kitchen/food service area at 11:07AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and nonperishable food. Food labels were inspected and checked for expiration dates and food labels had expiration date clearly marked. Knives and chemicals were locked and inaccessible in the cabinet under the sink.

BEDROOMS: There are five (5) bedrooms total; two (2) are private resident bedrooms, two (2) are shared-resident bedrooms, and one (1) is a staff room which is kept locked and inaccessible. Bedrooms #1, #3 and #5 have direct exits to the exterior. LPA observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, sufficient lighting, and equipped with functioning auditory exit alarms. LPA observed Resident #1 (R1) residing in Bedroom #5, however, R1’s physician’s report signed and dated 05/08/2025 marks R1 as bedridden, and the facility’s fire clearance only clears Bedroom #1 for bedridden-use. Bedroom #5 does not have fire clearance for bedridden-use. Administrator stated that R1 can reposition and self-transfer, and Administrator will contact R1's physician to get an updated physician's report regarding R1's ambulatory status.

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 SPACES/LAUNDRY: This includes the living room and dining room. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Living room contained a fireplace that was adequately screened. The LPA observed the required postings in the common hallway. Fire extinguishers were fully charged and last serviced 05/19/2026. The facility smoke alarm system is hard wired; the combination smoke and carbon monoxide detectors were tested at 11:46AM and were operable at the time of the visit. LPA observed the locked laundry unit in the hallway which contained detergents inaccessible to residents.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water on the premises. There is a self-latching gate on the side of the house designated for an emergency exit. Passageways were free and clear from obstruction.

MEDICATION REVIEW: At 11:22AM, LPA observed the medication refrigerator with a non-functional lock and medications accessible to residents. Administrator secured the refrigerated medications during the visit. At 11:50AM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in the hallway closet. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs were properly documented and logged. At 11:55AM, LPA observed Resident #2 (R2)’s melatonin tablets and calcium tablets logged on the centrally stored medications and destruction record with missing start dates. Administrator corrected the start dates during the visit. LPA observed Resident #3 (R3) with orders for insulin injections, but the injections are not pre-filled syringes or self-administered pens. R3’s physician’s report signed and dated 08/27/2024 states that R3 can self-administer injections but cannot prepare the syringe. Administrator confirmed that staff are filling the syringes and LPA informed that only licensed medical professionals can fill the syringe. Administrator stated that R3's home health nurse will pre-fill the syringes and Administrator will contact the prescribing physician for insulin pens rather than syringes.

Report Continued on LIC 809-C

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control policy and emergency disaster plan. Emergency disaster plan is updated annually as required and emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 03/12/2026. All documents reviewed were updated and in compliance.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Civil penalty was issued in the amount of $500 for fire clearance violation. Administrator was informed that failure to correct deficiencies may result in additional civil penalties.

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