Routine inspection·June 27, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:45 AM. LPA met with facility staff who contacted the Licensee Representative Carrie Acosta. The Licensee Representative arrived to the facility at 10:13 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 10:15 AM the LPA, along with the Licensee Representative 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: COMMON AREAS : This includes the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains a television and activities for resident use. Additionally, the living room contained a fire extinguisher that contained a tag stating the last service was conducted on 06/29/2025. LPA interviewed the Licensee Representative and asked why the tag was stamped for two (2) days from the date of today’s inspection (06/27/2025). The Licensee Representative stated that the fire extinguishers were serviced yesterday (06/26/2025) and were unsure why the person servicing them stamped the incorrect date. The dining area was observed to be equipped with adequate seating for resident use. Additionally, the dining room contained an extra refrigerator and a storage cabinet which contained resident medication. LPA observed a closet in the hallway to contain extra linens. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms were tested at 01:13 PM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms. LPA observed cameras located throughout the common areas of the facility and confirmed with the Licensee Representative that audio is not recorded. Continued on LIC 809C. KITCHEN : The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured under-sink cabinet to contain cleaning chemicals and a secured drawer to contain knives and other sharp objects. Adjacent to the kitchen was the facility’s washer and dryer closet. LPA observed secured storage containing laundry chemicals. BEDROOMS : There are four (4) bedrooms in the facility; three (3) are dual occupancy resident rooms and one (1) is a staff room. LPA and the Licensee Representative toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms #3 and 4 were observed to have narrow passageways due to furniture/clutter which would make it difficult for residents using a wheelchair or walker to traverse the room. Licensee Representative agreed to rearrange the rooms and remove clutter to allow for easy passage by residents. BATHROOMS : There are two (2) bathrooms at the facility. One (1) is designated as a shared/common resident bathroom and one (1) is a staff bathroom. The resident bathroom was observed to be relatively clean and was equipped with nonskid surfaces. The resident bathroom contained a toilet that was observed to contain a large piece of the ceramic broken off and missing on the water tank. Additionally, LPA observed an unsecured under-sink storage to contain cleaning chemicals. LPA informed the Licensee Representative of the deficiencies, the Licensee Representative agreed to replace the broken toilet and secured the chemicals at the time of the visit. Grab bars were observed in the resident shower and near the resident toilet. The water temperature was measured to be 115 degrees Fahrenheit, which is within the range required by regulation. OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front yard of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed a secured storage shed that contained miscellaneous care supplies and household items. LPA observed the garage and ADU on the property. The ADU was observed to be appropriately secured. LPA observed the garage to contain an additional refrigerator and the facility’s emergency food and water supply. LPA observed expired food items located in the garage. LPA informed the Licensee Representative who agreed to conduct an audit of the food items and remove any expired items from the storage. Continued on LIC 809C. RECORD REVIEW: Record review began at 11:35 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Two (2) staff files were reviewed. All staff files contained all required documentation. LPA did not observe staff training records located in the staff files. LPA interviewed the Licensee Representative who stated that the staff had started recently and had received approximately eight (8) hours of training. LPA informed Licensee Representative that staff are required to have a minimum of twenty (20) hours of training before providing assistance to residents. Licensee Representative agreed to conduct the additional training with staff. six (6) resident files were reviewed. One (1) resident file was observed to contain a physician’s report that did not contain accurate information on the resident’s current condition. LPA informed the Licensee Representative who confirmed that this is the most recent physician’s report they had on file. LPA informed the Licensee Representative that an updated Physicians report must be obtained following a change in condition of a resident. Licensee Representative agreed to obtain an updated physicians report for the identified resident. Additionally, LPA observed six (6) resident files to have incomplete and unsigned personal property inventory records. LPA informed Licensee Representative who agreed to complete the forms with each resident. LPA observed three (3) resident files to be missing signed copies of the personal rights of residents. LPA informed the licensee representative who agreed to obtain signed copies of the form for the identified residents. MEDICATION REVIEW: Medication review began at 01:04 PM. Medications for two (2) of six (6) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are to be conducted quarterly; the Licensee Representative was unable to provide LPA with the last date of the facility’s completed emergency disaster drill. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Licensee Representative. Continued on LIC 809C. INTERVIEWS: LPA interviewed three (3) residents. Two (2) residents interviewed stated that the staff treat them well and are attentive to their needs. LPA interviewed two (2) staff members with the assistance of telephonic translation services. The staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit the Licensee Representative agreed to email LPA a copy of the facility’s LIC 500, resident roster, and current liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.