Routine inspection·November 13, 2025

On 11/13/2025 at 11:30AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Flory Mae Muertequi, Caregiver and explained the purpose of the visit. The facility has a fire clearance for two (2) ambulatory and four (4) non-ambulatory residents. A hospice waiver for four (4) residents. LPA toured facility with Flory Mae Muertequi, Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of four (4) total bedrooms, and three (3) bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the residents. The hot water temperature in the resident’s shared bathroom was measured at 109.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of nonperishable and 2 days of perishable foods. Continues on LIC809C .... . Continued from LIC809. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 10/10/2025. First aid kit was observed to be complete. Fire drill last conducted on 09/01/2025. Emergency disaster plan reviewed on 05/30/2025. Four (4) staff records were reviewed; all four (4) staff were associated and has FirstAid. LPA reviewed six (6) resident records during visit. LPA requested the following documents to be submitted to CCLD by 11/20/2025 . LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan (last page) Liability Insurance Updated Facility Sketch LPA observed the following deficiencies during visit: At 12:22PM, LPA observed Insulin, Sorbitol Solution, Geri-Tussin, Docusate Sodium Liquid and Milk of Magnesia in resident’s shared kitchen refrigerator. Continues on LIC809C..... Continued from LIC809C At 1:42PM, LPA observed during file review, three (3) out of four (4) staff members are missing annual training records. At 1:56PM, LPA observed during file review, R1, R2, R3, R4, and R5 are non-ambulatory. R4 and R5 are in bedroom #4 that is approved for ambulatory only residents per fire clearance. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (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 were provided to Flory Mae Muertequi.