Routine inspection·September 3, 2025

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 9:36AM. The LPA was greeted by Staff, informed them of the reason for the visit, and Staff proceeded to notify the Licensee and Administrator. Licensee Jeffrey Alvarez and Administrator Madeleine Ayllon arrived at 10:56AM. Entrance interview conducted. Beginning at 9:53AM, the LPA and Staff toured the physical plant areas inside and outside to ensure there were no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: Knives were stored inaccessible in a locked drawer near the sink with cleaning supplies stored inaccessible and locked under the sink. The LPA observed the lower drawers to the right of the stove was not on its tracks/hinges and contained an unsecured hammer and butcher knife. The Staff secured the knife and hammer immediately. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable food and did not have a sufficient supply of non-perishables. The Licensee purchased non-perishables during the visit. Non-perishables consisted of five (5) canned tunas located in the cabinet pantry. Interview with Staff and the Licensee revealed the facility did not have emergency food. Food in the refrigerator and freezer were observed to be properly stored and labeled. The LPA observed the lower fridge drawer containing produce was also in disrepair and was sitting on the bottom of the fridge, not on the hinges. Report Continued on LIC 809-C COMMON AREAS: At the time of the visit, the facility had two (2) living rooms, a dining room, and a den with furniture observed to be in good condition. Dining room cabinets contained unsecured medications which the Staff stated were old and belonged to prior residents. The Staff discarded of the medications. Required postings were in the entryway hallway and the dining room. The LPA observed water damage on the ceiling, above the dining table. The two (2) ceiling planks were lifting, had water stains, and cracks. The LPA observed emergency water stored near the second living room. The hallway closet contained extra linens, and the closet doors were in disrepair as they were leaning and not aligned with the closet tracks. The Staff stated it has been broken for 2 months. The facility maintained a comfortable temperature throughout the visit. BEDROOMS/RESTROOMS: There were six (6) total bedrooms: one (1) staff room, one (1) guest room, and four (4) private resident rooms. Bedroom #5 had a direct exit to the outside and was approved for one (1) bedridden resident. The guest room was occupied by a family member of the Licensee who was fingerprint cleared but was not associated with the facility. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Bedroom #4 had window blinds that were in disrepair with seven (7) panels broken off. There were four (4) total restrooms in the facility: two (2) staff restrooms, one (1) private resident restroom, and one (1) shared resident restroom in the hallway. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. The shared resident restroom contained a closet with extra linens and towels. One (1) staff restroom had accessible cleaning supplies, laundry detergent, and insect aerosol sprays. Hot water was tested and measured between 97 degrees F and 138.2 degrees F, which was not in the required range of 105 degrees F and 120 degrees F. The Licensee stated they would lower the water temperature. OUTDOOR AREA: The surrounding grounds had one (1) shaded patio area equipped with furniture in good condition for residents and visitors to use. There were two (2) manual driveway gates, and two (2) self-latching gates used for emergencies. No bodies of water noted, and exits were free of obstructions. Report Continued on LIC 9099-C The rear had laundry machines that were observed to be operational with a nearby garage. The garage contained general storage and had a broken door handle that was inoperable. The LPA and Staff pushed the garage door open to gain access. RECORDS: Record review began at 11:07AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. Resident #1 (R1) did not have a TB test result on file. The Administrator contacted their Physician who stated a skin test was not done and would check for X-Ray results. At this time the facility could not provide the LPA the TB results. Four (4) out of four (4) residents’ Pre-Placement Appraisal and Appraisal/Needs and Services Plans were completed but did not have the residents’, or their representative’s, signatures. The Administrator stated they review all documents with the families over the phone, however, did not obtain signatures. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. The LPA discussed the documentation of staff training to include the training hours, per regulation. The Administrator understood. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 07/15/2025. Smoke and carbon monoxide detectors were tested at 11:06AM and were operational at the time of the visit. Two (2) fire extinguishers were observed throughout the facility and were last serviced on 08/05/2025. Report Continued on LIC 9099-C MEDICATIONS: Medication review began at 12:17PM. Medications were centrally stored and kept inaccessible in the hallway cabinet located between the staff room and staff restroom. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record. R1 had Acetaminophen 650MG filled on 12/26/2024 that was not documented. Resident #2 (R2) had two (2) Quetiapine Fumarate 25MG filled on 08/01/2025 and 08/25/2025, and two (2) MAPAP 500MG filled on 07/11/2025 and 08/04/2025 that were not documented. The Administrator stated that Staff must not have documented the medications because it was not yet in use. Additionally, R1 did not have a PRN (as needed) Authorization Letter. R2 had an outdated PRN Authorization Letter that did not reflect the current PRN medications they were taking. The Administrator stated they would contact Hospice to obtain the letters. Pursuant to Title 22 CA Code of Regulations and/or Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report were reviewed and provided.