Routine inspection·February 28, 2026

Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conducted an Annual Required Inspection visit. When LPA arrived she was greeted by the designee, Marilyn Marbella. Staff contacted the Administrator, Roderick Flores and informed him LPA was at the facility. LPA explained the purpose of the visit. Administrator arrived 1:30 PM and met with LPA in the facility. In the facility LPA observed two (2) residents sitting at the dinning table eating breakfast. At approximately 8:21 AM, LPA initiated the physical plant tour of the facility inside and out. At the entrance LPA observed appropriate postings and a sign in log for visitors. At 8:23 AM LPA requested a copy of the facility's Emergency Disaster Plan (610E) for review and to update the Regional Office file. The administrator certificate posted is active. LPA observed the fire extinguisher on a wall in the common area. The fire extinguisher was fully charged and had a service tag indicating it was last serviced on 09/05/2025. The facility has an open concept layout that includes the kitchen, living area, and dining area. In the kitchen LPA observed appliances and fixtures were functional. LPA observed cookware and residents’ tableware to be in good repair. LPA observed a sufficient amount of two-day perishable and 7 day non-perishable food in the refrigerator and pantry. Knives and sharps were stored in a locked cabinet. LPA observed a staff washing dishes and cleaning the kitchen counters. The facility telephone is accessible to residents on the kitchen counter. (Continue to LIC809-C) In the living area and dining area LPA observed the furniture to be in good repair and sit the capacity of the facility. There is a television, activity books and puzzles for residents. LPA did not observe tripping hazards. Doors leading to the outside have auditory alarms there were on and functioning properly during the visit. There are five (5) bedrooms designated for residents. Bedroom #5 can be shared. The facility has a fire clearance (STD850) dated 01/07/2026, designating Bedroom #2 for a bedridden resident and all other bedrooms for non ambulatory residents. Bedroom designated for residents use were furnished with a bed, night stand, chair, dresser, bedding, sufficient lighting and closet space. LPA observed half bed rails on Resident #1's (R1's) bed in bedroom #1. LPA observed full beds rails on Resident #2's (R2's) bed in bedroom #2. In the hallway leading to bedrooms #4 and #5, a carbon monoxide detector was observed and tested at 8:36 AM, and it was functioning properly. LPA observed smoke detectors through out the facility. LPA observed the designee test them at XX:XX PM and they were observed functioning. The facility has two (2) bathrooms . Bedroom #5 has a private bathroom. The other bathroom is located in the hallway, outside of bedroom #4 and #5. LPA observed the bathrooms had functioning plumbing and fixtures equipped with grab bars, and non-skid mats. The hot water delivered in the common bathroom was measured at 8:40 AM and read 113.8 degrees Fahrenheit, within regulation. The backyard has a shaded area with a table. LPA observed the passageways to the exit were clear of obstruction. The facility had removed pavers and will remodel backyard. Currently the backyard has a space with concrete flooring and dirt but still offers a sufficient amount of out door space for residents. There is no swimming pool or bodies of water. The garage is attached to the facility and has an entrance through the laundry room. Detergents and cleaning supplies are kept locked, in the laundry room . LPA observed a second refrigerator in the garage where the overflow of food is stored. The garage is also used for storage and has emergency food and water. (Continue to LIC809-C) Page 2 of 3 (Continued from LIC809-C) Facility records for staff and residents along with medication were observed locked in hallway cabinets. From 9:25 AM to 12:00 PM, LPA conducted a file review of five (5) resident files to ensure licensing forms were complete and in compliance. Review of the medical assessment (LIC 602A) indicated that R1's ambulatory status is bedridden due to physical condition. R1 is residing in a non ambulatory bedroom. According to designee, R2 is in bedroom #2 because they are bedridden. LPA's review of medical assessment (LIC602) identifies R2 as non ambulatory although LPA observed other documentation indicating a bedridden status. LPA could not find and was not provided a half bed rail order for R1. LPA could not find and was not provided a full bed rail order for R2. LPA's review of Resident #4's (R4) file revealed R4 did not have a re appraisal completed since resident was admitted and later discharged from skilled nursing on 08/08/2025. LPA also observed a medical assessment (LIC602) for R4 from 2022 but no routine annual visit was on file for R4. In addition, LPA also conducted a file review of three (3) staff records to insure training documents are in compliance and complete. Medication and Medication Records were reviewed for proper storage and documentation. LPA reviewed and obtained copies of the Register of Facility Residents (LIC9020), Personnel Report (LIC500), and the facility’s liability insurance to update the Regional Office file. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were deficiencies observed during the visit. Refer to LIC809-D. An immediate Civil Penalty was assessed. Exit Interview was conducted and a copy of the report was provided to the Administrator. Page of 3 of 3