Beginning at 09:45 AM the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer which contained knives and other sharp objects. LPA observed a fire extinguisher mounted on the wall that was last serviced on 04/08/2026. The kitchen contained a locked under sink cabinet which contained cleaning supplies and an additional locked cabinet which contained resident medications and facility files.

BEDROOMS: There are four (4) bedrooms in the facility; two (2) are dual occupancy resident rooms and two (2) are single occupancy resident rooms. LPA and the facility Administrator toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. All four (4) bedrooms contained a direct exits to the outdoors of the facility.

CONTINUED ON LIC 809C.

• 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 AREAS: This included the living room and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained a television and activities for resident use. Additionally, the living room contained an additional fire extinguisher that was last serviced on 04/08/2026. The dining area was observed to be equipped with adequate seating for resident use. LPA observed a closet to contain the facility’s washer and dryer. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms were tested at 10:30 AM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms.

OUTDOOR SPACE: The facility has two (2) emergency exit gates located in the front yard of the facility; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. LPA observed a secured storage shed that contained miscellaneous care supplies. LPA observed an unsecured bottle of floor cleaner in the backyard of the facility. LPA notified the Administrator who immediately secured the item.

RECORD REVIEW: Record review began at 10:31 AM. 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, consent forms, and personal rights. Six (6) staff files were reviewed. All staff files contained all required documents and trainings. Five (5) resident files were reviewed. All resident files contained all required documentation and signatures.

CONTINUED ON LIC 809C.

MEDICATION REVIEW: Medication review began at 11:13 AM. Medications for three (3) of five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 04/20/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

INTERVIEWS: LPA interviewed two (2) residents. One (1) resident interviewed stated that the staff treat them well and are attentive to their needs. One (1) resident interviewed had concerns with the facility. LPA interviewed two (2) staff members with the assistance of the Administrator acting as a translator. The staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, emergency disaster plan, and current liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.