Routine inspection·December 2, 2025

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for six non-ambulatory residents. Facility has an approved hospice waiver for four residents and the home currently has four residents, with no residents on hospice. Administrator (AD) Cynthia Shayamunda arrived shortly to assist with the inspection. AD provided updated liability insurance that expires on 4/06/2026. LPA along with staff toured the facility at 9:05 AM. LPA toured the physical plant, checked food service, and facility documentation. The home consists of five resident bedrooms, living room, dining room, and kitchen, two bathrooms and an attached garage. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed bed rails for three resident beds. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 131.5 degrees F and 134 degrees F in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Four out of five auditory exit alarms were not operational during today's visit. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 09/20/2025. Outside grounds were toured. Continued on LIC809-C dated 12/2/2025 Exit Walkway by bedroom 4 is obstructed with old furniture and wood planks. There is shaded outdoor seating for residents. Exit gates are unlocked. Exit gate by bedroom 4 is missing a pull string, making it challenging to open. LPA observed the emergency food and water supply. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of games. LPA reviewed four resident files and two staff files. Resident files contained required documentation including admission agreements, physician reports, and resident appraisals. Three out of four resident files did not include evidence of bed rails orders by a physician. One out of two staff files reviewed contained all required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. Medications are stored in a locked closet. Medications are being administered per physician order. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.