Routine inspection·July 28, 2025

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. Resident record review began- Five (5) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is not meeting documentation requirements. Employee records review began- Two (2) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to meet the needs of the clients in care. Administrator certification is present and current 07/10/2026 Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 115.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals inside the garage. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. (Continued on Page 2) (Continued from LIC809, Page 1) Food Service- Food supply meets the of one week supply of nonperishable and 2-day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. LPA observed three (3) pilot lights for stove are not working. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation, and the structure has been changed not according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 7/07/2025. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 07/01/2025. LPA observed a make shift room inside the garage for family members. The layout for the bedrooms has been changed and does not match the approved floor plan. The facility has a hospice waiver for two (2) and LPA observed hospice records for three (3) residents. Based on the information received during this visit today, there are five (5) deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. This report, LIC809D, Appeal Rights was reviewed with Joi Mae at the time of the exit interview and a copy will be emailed with confirmation request.