Routine inspection·March 24, 2026

At approximately 12:10PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Staff Members, Elma Cordero and Elijha Cintron. Licensee/Administrator, Silvana Daniel arrived at approximately 12:20PM. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 8 non-ambulatory residents. Facility has an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there were 7 Residents in care and 2 staff members on-site. At approximately 12:15PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Licensee/Administrator and observed the following: facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 7 Resident bedrooms, 1 staff bedroom, 4 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. LPA observed instances of unlabelled or expired foods in facility fridge. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Facility's cleaning supplies and laundry detergent were observed to be accessible during visit in laundry room. It was observed that facility has a cabinet for cleaning supplies but it was unlocked with the key attached during visit. Facility's fire extinguishers was last inspected November 2025. Facility's last emergency/disaster drill was conducted January 2026. Facility's emergency disaster plan was last reviewed and updated on 03/01/2026. LPA reviewed 2 staff files and 4 resident files. LPA also reviewed resident medication. Staff files had current First Aid/CPR Continued on LIC809 Continued from LIC809 certification. Review of Staff Member 1's (S1) file was found to be missing proof of health screening. Review of last year's annual visit indicated that S1 did have a health screening on file but Licensee was unable to locate it during this year's annual visit. Review of Staff Member 2's file (S2) was found to be missing proof of their initial 40 hours of training. 1 of 4 resident files were found to be missing an updated needs/services plan. It was observed that another resident is considered bedridden per their medical assessment. Further review showed that this resident is receiving hospice services and facility sent notification to the Marin Fire Department. Facility to clarify fire clearance with Marin Fire Department and to submit an updated facility sketch to Community Care Licensing by 04/03/2026. LPA conducted review of resident medication. LPA observed that resident central storage logs were not documented correctly and had errors such as missing quantity of medication, incorrect dosage, incorrect expiration and fill dates, and not writing out the complete medication instructions. LPA also observed that medications were being prepoured in advance. LPA observed that 5PM medications were poured for a resident. Per Licensee, the medication had been poured that day around 11AM. LPA and Licensee discussed filling out the Centrally Storage Log (LIC622) accurately and live medication pouring expectations. Administrator's Certificate for Licensee, Silvana Daniel, (7036051740) was current with an expiration date of 03/21/2027. LPA is requesting the following documents to update facility file: LIC308 – Designation of Facility Responsibility LIC500 - Personnel Report LIC610E - Emergency Disaster Plan Updated Liability Insurance Documents to be submitted to Community Care Licensing by 04/24/2026. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Licensee. Signature on form confirms receipt of documents.