Routine inspection (multi-day)·December 30, 2025

Licensing Program Analyst (LPA) Elena Mallett conducted an unannounced Annual Continuation visit to complete the CARE tool domains that were not completed during the original visit. The original visit was conducted on 12/29/25. LPA Mallett was met by Administrator Hiransha Keerthisinghe and the purpose of the visit was explained. The facility is licensed to serve 6 Non-Ambulatory Residents, one of which may be bedridden, ages 60 and above, with a hospice waiver for (4) four. Currently none of the residents are bedridden. One resident is on hospice. LPA utilized Compliance and Regulatory Enforcement (CARE) tools for the visit today and for the initial visit. LPA observed the following during today’s visit: Infection Control: Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan and facility maintains current, required liability insurance. Physical Plant & Environment Safety: Staffing : There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. (Continued on LIC809-C) Personnel Records-Training : Staff files are kept in a secure area. All staff have criminal record clearances, current First-Aid/CPR/AED training along with annual ongoing Dementia and Care for the Elderly population training documented in personnel files. LPA reviewed 3 staff files with no issues observed. Administrator Hiransha Keerthisinghe certificate expires on 05/13/26. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisals, Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Reports with ambulatory status. LPA reviewed 4 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities and has a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a locked closet and are in their original containers. 4 resident medication logs were reviewed with no issues. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. A complete First Aid kit with Manual was observed. Operable emergency lamps were observed. Residents with Special Health Needs: There are no bedridden residents at this time. One resident is using hospice, and a hospice care plan was observed. Three staff and four resident interviews were conducted. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. An exit interview was held with Administrator Keerthisinghe and a copy of this Licensing report was provided.