Routine inspection·November 20, 2025

On 11/20/2025 at 10:50 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Marjoy Bacuyag and explained the purpose of the visit. Marjoy Bacuyag phoned the administrator, Keith Mauer to inform. The facility’s fire clearance was approved for six (6) residents in which all may be non-ambulatory. Hospice waiver approved for two (2) residents. Administrator certificate #7027929740 expires 08/08/2026. Keith arrived approximately 30 mins later. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of six (6) total bedrooms that are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. LIC809-C LIC809-C (Page 2) Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 07/22/2025. Emergency Disaster Plan was last posted on 11/20/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 11/12/2025. LPA reviewed four (4) residents records. LPA reviewed five (5) staff records and all staff have current first aid training and associated to the facility. LPA reviewed all four (4) resident’s medications. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/27/2025: LIC 308 Designation of Administrative Responsibility - Reviewed LIC 309 Administrative Organization - Reviewed LIC 500 Personnel Report - Reviewed LIC 610E Emergency Disaster Plan - Reviewed Liability Insurance - Reviewed Current Administrator’s Certificate - Reviewed The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.