Routine inspection·April 22, 2025

On 04/22/25 at 12PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (S1) and explained the purpose of the visit. LPA spoke with ADM on the phone who authorized S1 to act on her behalf and sign the reports. LPA observed ADM has a current administrator certificate# 6056379740 which expires 09/26/2027. At 12:30PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. LPA observed kitchen table cover sticky. LPA also observed broken tile on kitchen counter and broken back porch sliding door screen. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 74 deg F. Hot water temperature was measured at 115 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Smoke and Carbon monoxide detectors were operational. LPA reviewed 2 staff and 2 resident files. Fire extinguisher was observed fully charged and last inspected on 05/21/24. Continued on next page, LIC 809-C The following deficiencies were observed during visit: Broken back porch sliding door screen. Sticky dining table cover in kitchen area. Broken kitchen counter tile Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties . Exit interview conducted. Appeal Rights and a copy of this report provided.