Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to six elderly residents, up to five may be non-ambulatory and one may be bedridden. The bedroom at the entrance of the facility is only for one ambulatory use. Facility does not have a clearance for delayed egress, and locked exterior/interior. Facility has a hospice waiver for 2 residents.

Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident units, resident bathrooms, dining room and outdoor areas.

LPA inspected 5 resident bedrooms and 2 bathrooms. Bathrooms are equipped with non-skid flooring and grab bars. Faucet, toilet and shower are in working condition. Hot water temperature was 114 degrees Fahrenheit in one of the bathrooms. Room temperature was maintained at 72 degrees Fahrenheit throughout this visit. There is a fire door leading to the residents’ bedrooms. Per fire safety, advisory was provided to ensure the fire door is closed at all times.

In the kitchen/dining area, LPA observed at least 7-day nonperishable and 2-day perishable food items. Knives/sharps and cleaning chemicals were locked under the sink. Fire extinguishers observed and last serviced on 5/5/2026. Fireplace was observed to be screened. Smoke detectors were observed throughout and one carbon monoxide detector. Adequate linen supply was observed. Medication was observed to be locked and not accessible to residents. Advisory was provided to ensure foods that are contaminated or moldy are discarded.

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• 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.

Record Reviews: Review of 3 of 6 resident files was conducted, including but not limited to, review of Admission Agreement, Physician Reports, and Ambulatory Status. Advisory was provided to ensure all residents’ Care Plans (LIC625) are complete. Per review of resident records, at least one person was assessed to be at risk if they have direct access to nutritional supplements. Advisory was provided to ensure all nutritional supplements are not accessible to residents in care.

Medication review was conducted for 2 residents, including review of resident’s medication, PRN authorization letter, prescription records, Centrally Stored Medication Records, and Medication Administration Records. Advisory was provided to ensure each resident has current PRN authorization letter. Advisory provided to ensure medications are not pre-poured ahead of time. Current RCFE Medication Guide was provided.

Review of 2 staff files included but not limited to background clearance, first aid/CPR certification, and training.

Facility conducts monthly Fire/Emergency Drill. Advisory provided to facility to review their Emergency Disaster Plan and Infection Control Plan at least annually and document each review.

Interviews: One staff member and one resident in care were interviewed.

Documents Requested: LPA requested a copy of updated Liability Insurance, LIC500, and LIC308.

Per the California Code of Regulations, Title 22, Division 6, no deficiencies were cited.

Exit interview was conducted with AD. A copy of the report was provided upon exit.

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