Routine inspection·September 12, 2025

On September 12, 2025, Licensing Program Manager (LPM) Sheila Santos and Licensing Program Analyst (LPA) Garlli Tat conducted an unannounced visit to the facility for the purpose of a required annual inspection. LPA explained the purpose for the visit and was greeted and granted entry by staff on duty. During the visit, staff on duty contacted the facility administrator (AD) Alicia Lira about the visit. For this visit, there are three staff members on duty, all of which are background cleared and associated. AD later arrived to assist with the inspection. The PUB475 ‘See Something, Say Something’ poster was observed to be located by the front entrance. LPA observed the Administrator's Certificate for Alicia Lira, which expires on December 14, 2026. The facility is a Residential Care facility for the Elderly (RCFE) licensed for six residents, six of which may be non-ambulatory, none of which may be bedridden, and three of which may be on hospice. LPA toured the interior and exterior portions of the facility with AD. For this visit, there are a total of four non-ambulatory residents in care, two of which are on hospice, and none are bedridden. The facility is a two story home. There are a total of seven bedrooms, six of which are private resident rooms, and one serves as staff quarters. LPA toured each bedroom with the AD and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and free of any hazards. LPA observed the staff quarters to be kept locked and inaccessible to residents in care. Smoke and carbon monoxide detectors as well as auditory exit alarms were tested and operational. There are a total of four bathrooms, three of which are for residents and one is for staff. Page 2. Restrooms were observed to be in good repair, toilets and faucets were operational and showers were equipped with grab bars and non-skid floor mats. Water temperature in the bathrooms were measured to be between 105.6 and 109.2 degrees Fahrenheit. Facility met the minimum two day perishable and seven day non-perishable food supplies. Sharp items and knives were locked in the kitchen and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen. Fire extinguishers were dated and tagged on May 16, 2025. LPA observed the emergency disaster and evacuation plan, which is posted in the dining room. Facility had back-up emergency food and water supply, located in the garage. LPA observed that the First Aid kit had all the required components. Medications and toxins were also observed to be locked in a cabinet in the kitchen, inaccessible to residents in care. For residents #2 and #4, medications were improperly administered. For the exterior portion, LPA observed patio furniture under shading. LPA observed a ladder in the backyard, which was accessible to residents. The ladder was later removed and made inaccessible by staff. There is one self-latching gate in the backyard that can be opened in case of an emergency. No bodies of water were observed. Based on today's observations, there are two deficiencies being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Alicia Lira. This report was reviewed with the administrator and a copy was provided at the end of the visit. Appeal Right were reviewed.