Routine inspection·September 2, 2025

License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required inspection of the facility. LPA was welcomed by designee/staff Gladys Flores. Elizabeth Allen Licensee/Administrator was contacted by staff although unable to attend today’s inspection, authorized designee to sign for today’s visit. Facility is single story with 5 bedrooms that Novato Fire has granted clearance for 6 Non ambulatory residents. Facility has hospice waiver for 2. There is a total of 4 residents, 2 with a major neurocognitive disorder diagnosis and none on Hospice. LPA toured the facility on 9/2/2025 at 8:45 AM with designee/staff Gladys Flores; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices which were working properly at the time of the visit. Fire Extinguisher was found to be last charged on 9/24/2024. Smoke detectors and carbon monoxide were found to be operational during the visit. Hot water temperature measured 106.3 to 116.6 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 out of 2 resident’s bathrooms while touring facility on 9/2/2025 at 8:45am. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the laundry/garage room; although bleach was observed under resident bathroom sink without lock (see pics & LIC809D).There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations. Continue on LIC809-C Continued from LIC809 All bedrooms have lighting & appropriate furnishings. At the time of the visit LPA observed that 1 out of 4 residents (R1)’s Medical Assessment (LIC602A) indicates admitted to facility with Bedridden diagnosis & not able to independently transfer (has and is not under Hospice care). Facility does not have fire clearance for bedridden residents (see LIC809D). A review of four resident & four staff records as well as two resident’s medications records was conducted. LPA reviewed resident’s files at 10:00 AM on 9/2/2025 and learned that 4 out of 4 residents have a current reappraisal on file. In addition, 4 out of 4 residents have required physician’s report. Medications were centrally stored in a locked medication cabinet in the dining room of the facility; although there were additional medications pre-poured stored in drawer next to centrally stored without being locked (see LIC809-D). The Medications of 2 out of 2 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to not be complete and accurate on 9/2/2025 (see LIC809D). LPA reviewed a sample of staff records at 11:00 AM on 9/2/2025 and learned that all facility staff present and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff at the facility have received the additional training requirements. LPA was presented with proof of CPR & 1 st Aid certification for staff that files were reviewed. Elizabeth Allen Administrator Certificate #7003030740 expires on 10/21/2025. Disaster Drills have been conducted quarterly with the last conducted on 7/8/2025. In order to request a bedridden fire clearance, the following documents are to be sent to CCL no later than 9/3/2025: An LIC200 filled out entirely showing 1 bedridden in section 10B & An updated facility sketch identifying bedridden room. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. LPA Hansen is requesting Licensee to submit the following documents to CCL by 9/19/2025: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurance