Routine inspection·July 11, 2025

On July 11, 2025, at 10:15 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrator Martha Serna and explained the purpose of the visit. The facility is licensed to operate for six (6) non-ambulatory, of which one (1) can be bedridden and has a hospice waiver for six (6) residents. The facility is a single-story building located in a residential neighborhood. It consists of the following: five (5) residents bedrooms, one (1) staff bedroom, four (4) bathrooms, an attached 3-car garage, living area, outdoor pool, dining area, kitchen, and an outdoor covered seating area. LPA Kim toured inside and outside of the physical plant. The outdoor pool is fenced and inaccessible. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident room 1, resident room 2, resident room 3, resident room 4, and resident room 5. Bathrooms were found to be clean and operational. The water temperature measured between 107.7 degrees F and 128.8 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, residents, and sanitizing stations in common areas. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water and emergency supplies are stored in the garage. All mandated inspection control posters were posted. The facility has smoke detectors and carbon monoxide detectors that were operable. The Certificate of Liability Insurance is effective from June 20, 2025, to June 20, 2026. The facility has not conducted any Fire/Safety Drills. One (1) fire extinguisher was mounted in the kitchen. A working telephone (714-773-0055) remains available. First Aid Kit contained all the necessary elements. LPA Kim conducted an audit of six (6) residents (R1-R6) files, and four (4) staff (S1-S4) personnel files, and medication and medication administration records. S1 was missing a LIC503 that was filled out. LPA conducted interviews for two (2) resident interviews and one (1) staff interview. Based on today’s visit, deficiencies are being cited as per Title 22 Division 6 Chapter 8 of California Code of Regulations (CCR). LPA observed the water temperature in shared resident bathroom measured at 126.5 degrees F and the resident room #5 private bathroom measured at 128.8 degrees F. An exit interview was conducted, and a copy of this report, appeal rights, and LIC811 were provided to Administrator Martha Serna.