Routine inspection·July 8, 2025

Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced annual visit at this facility. LPA was greeted and granted access by staff #1 (S1). The administrator designee, Khristine Campbell met with LPA shortly after and LPA explained the purpose of the visit. The facility has an approved fire clearance for five (5) non-ambulatory and one (1) bedridden resident in Room #5 for a total capacity of 6. The facility has a Hospice waiver for two (2) residents. A tour of the physical plant inside and out was conducted at 9:15 a.m., and the following was observed: At entry LPA observed a screening area where visitors can sign in, hand sanitizer, and face masks available. LPA observed appropriate postings on a wall by the front entrance. Kitchen: LPA conducted a tour of the kitchen and observed there to be sufficient supply of two day perishables and seven day non-perishables foods, properly stored. Food storage and preparation areas are clean and clear of clutter. LPA observed all knives, sharp object, locked in a kitchen drawer inaccessible to residents in care. There is one (1) fire extinguisher located in the kitchen was fully charged with purchase date 02/12/2025. A first aid kit with an up-to-date manual was observed in a kitchen drawer. Centrally stored medications are maintained locked in a kitchen cabinet. There are cordless telephones available to residents. Common areas: LPA observed the living area, breakfast nook and formal dining area to be clean and clear of clutter. The furniture was in good repair and sits the capacity of the facility. In the breakfast nook LPA observed games and hand therapy tools to assist residents with dexterity. (Continue to LIC809-C) (Continued from LIC809) Surrounding Grounds : Entry and exits were free of obstructions. There is a covered patio with appropriate furniture. There are no bodies of water and the backyard is fenced in. Laundry and Garage: Laundry room was observed locked. Detergents and cleaning supplies are kept locked in the laundry room. The garage can be accessed through the laundry room. Bedrooms: There are five (5) resident bedrooms. Four (4) out of five (5) bedrooms are for private use. LPA observed each resident room to be properly furnished with beds, appropriate night stand, chair, bedding and have sufficient lighting and storage. LPA observed the administrator designee test a dual smoke and carbon monoxide detector at 9:24 a.m. Detectors are interconnected to other detectors located through out the facility. LPA observed detectors functioning properly. LPA observed fire doors close when smoke detectors were tested. Bathrooms: The facility has three (3) bathrooms. One (1) is located in a resident's private bedroom. Bathrooms were clean and properly supplied with hand soap, toilet paper, and paper towels. LPA observed non skid shower mats and proper grab bars by showers and toilets. LPA observe night lights leading to hallway bathroom by bedrooms. Facility has a linen closet that stores extra bedding, towels and hygiene products. LPA observed a second closet with emergency food, water and supplies for a disaster. Resident/Staff/Facility Records: At 9:57 a.m., LPA reviewed two (2) of two (2) resident records to insure compliance with licensing forms. At 10:14 a.m., medications and Centrally Stored Medication and Destruction Records were reviewed for proper documentation. Medication records are maintained manually and facility keeps Medication Administration Records (MAR) as well. At 10:18 a.m, LPA reviewed two (02) staff records to insure compliance with licensing forms. LPA reviewed facility's Liability Insurance Policy, LIC 500, emergency disaster training for fire drill conducted on 05/2025, and infection control plan reviewed 05/2025. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit Interview Conducted. A copy of this report provided.