Routine inspection·June 6, 2025

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 9:50AM. LPA met with Licensee/Administrator Susan Caldwell. Entrance interview conducted. Beginning at 9:52AM, the LPA, along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN/LAUNDRY: Kitchen appliances appeared clean and were in operable condition at time of visit. Facility had a sufficient supply of perishable and nonperishable food. Food labels were inspected and checked for expiration dates. Knives and sharps were stored locked in staff bathroom by kitchen. Cleaning supplies, washer and dryer, and detergents were located in the locked laundry room adjacent to the kitchen. BEDROOMS : There are five (5) total bedrooms in the facility; four (4) are designated as private resident rooms and one (1) is a shared resident room. Bedrooms #1, #3, #4, and #5 have direct exits to the exterior. LPA observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, sufficient lighting, and equipped with functioning auditory exit alarms . BATHROOMS : There are five (5) total bathrooms; four (4) are for resident use and one (1) is kept locked for staff use and medication/sharps storage. LPA observed resident restrooms equipped with grab bars and slip-resistant surfaces. Hot water temperature was measured in resident bathrooms and were within the required range. Report Continued on LIC809-C. COMMON AREAS : This includes the living room, dining room, den, and sitting room areas. LPA observed common areas to be clean and properly furnished at the time of the visit. LPA observed surveillance cameras in common room which do not record audio. Fireplace in the living room was adequately screened. LPA observed a storage space closet in hallway containing clean linens for resident use. The facility smoke alarm system is hard wired; the combination smoke and carbon monoxide detectors were operable at the time of the visit. The fire extinguishers were fully charged and last serviced 03/26/2025. LPA observed required postings upon entry. OUTDOOR SPACE/GARAGE: The backyard has covered patio areas with patio furniture including tables and chairs for resident use. All passageways were clear and free of obstruction. There were no bodies of water on the premises. LPA observed a guest house in the backyard where Licensee/Administrator lives. LPA observed the front gate to be unlocked and self-latching, as is required. The detached locked garage is used as the facility office. RECORD REVIEW: Beginning at 10:30AM, LPA reviewed six (6) out of six (6) resident files and three (3) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training, first aid certification, and fingerprint clearance. All resident and personnel files were in order. MEDICATION REVIEW: At 11:47AM, LPA reviewed medications for two (2) residents. Medications were centrally stored and locked in the staff bathroom by the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order and authorization letter on file. Medications are labeled and were checked for expiration dates. At 12:14PM, LPA observed a label for Resident #1 (R1)’s Pantoprazole 40mg originally instructing to take at evening but was crossed out by staff and altered to take at morning before breakfast. Administrator stated that staff were instructed by the prescribing doctor but could not provide a written order for the change in instruction. Administrator contacted the prescribing doctor and pharmacy requesting a written order for the change. At 12:44PM, LPA observed as needed Acetaminophen 650 mg for Resident #2 (R2) that expired 03/30/2025. Administrator contacted the prescribing pharmacy for a new cycle. Report Continued on LIC809-C. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control policy and emergency disaster plan. Emergency disaster plan is updated annually as required and emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 04/25/2025. All documents reviewed were updated and in compliance. The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct deficiency may result in civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.