Routine inspection·February 3, 2026

At approximately 11:30 AM, Licensing Program Analysts (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Linda Mahlman, Licensee. Facility is a Residential Care Facility for the Elderly (RCFE) with four (4) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for one (1), is approved for fifteen (15 residents, five (5) of whom can be non-ambulatory. At approximately 12:00 PM, LPA initiated a tour of the facility with Licensee and observed the following: Facility is a two story home, was a comfortable temperature, and passageways were free from obstructions. Only facility staff live on the second floor of facility and residents do not have access to the stairs. LPA observed the following required postings missing from the facility communal area: CCLD reporting poster, emergency disaster plan, current administrator certificate, and resident's personal rights. Licensee agreed to post them immediately in order to operate in compliance with regulation. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods, as well as an emergency water supply. Licensee agreed to ensure all staff and miscellaneous medications are are securely stored and maintained inaccessible to residents in care in order to operate in compliance with regulation. There is a shaded seating area in the backyard with outdoor space for activities. LPA observed five gallon paint buckets stored in the back yard. Licensee agreed to move them into secured storage or dispose of them immediately in order to bring the facility into compliance with regulation. Continued on LIC809-C... Continued from LIC809... LPA observed the residents eating, resting in their rooms or watching TV. Facility has a piano, books, puzzles, and games available for residents in care. Facility has internet access and Administrator agrees to ensure an internet access device is designated for resident use. Facility telephone was tested an operational during inspection. Facility's fire extinguishers were observed charged and were last serviced 06/2025. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts three disaster drills per year with the last one completed on 10/2025. Licensee agrees to ensure drills are conducted no less than quarterly in order to operate in compliance with regulation. LPA observed the facility's infection control plan, first aid kit, PPE, flashlights, and emergency supplies. LPA observed a generator for emergency preparedness. LPA reviewed facility's emergency disaster plan which was last updated 01/2026. Licensee agrees to complete all sections of the emergency disaster plan and submit to the Department. At approximately 2:00 PM, LPA conducted file review. LPA reviewed four (4) staff and three (3) resident files and observed the following: Two (2) of four (4) staff files reviewed were missing some of the required annual training hours and annual medication training hours, (see LIC809Ds). All staff files were observed to contain all of the remaining required documentation, including proof of current CPR and first aid certifications. Three (3) of three (3) resident files reviewed were observed missing the consent for emergency treatment, which Licensee agrees to obtain immediately in order to bring the facility into compliance with regulation. LPA observed a fourth person in care who licensee was unable to provide the required documentation for, (see LIC809D). All resident files reviewed contained the remaining required paperwork per regulation. At approximately 3:30 PM, LPA reviewed medications and medication records which stored in compliance with regulation. However, LPA observed that the records did not accurately reflect the start dates and administration of the medications. LPA and Licensee reviewed proper documentation and practices and Licensee acknowledged understanding and agreed to operate in compliance moving forward. Administrator states that the residents families coordinate residents' medical and dental appointments and transportation to and from visits. However, facility will assist with coordinating these appointments and transportation for residents upon request. Facility does not manage P&I. continued on LIC809C... Continued from LIC809C... Updated copies of the following documents are to be submitted to CCL within 30 days of this visit : -LIC610E - Emergency Disaster Plan (updated) Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12 month period, may result in a civil penalty assessment. Exit interview conducted with Licensee whose signature on form confirms receipt of documents. Appeal rights provided.