Routine inspection·February 3, 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/Individual Program Plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA interviewed two (2) residents. 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 118.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals inside of room inside the home. 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. LPA observed a bottle of Lysol bleach toilet bowl cleaner under resident's bathroom sink, unsecured. Two exterior window screens need replacing and sliding door screen is missing. Food Service- Food supply meets the requirement 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 began review of employee records. Three (3) records were reviewed. LPA reviewed employee record for (Continued on next page) (Continued from page 1) for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and there current administrator certification CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and expired 07/29/2025. 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 remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguisher are tested or replaced annually and were last done so on 01/7/25. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 12/28/2024. There are no firearms stored and no bodies of water observed. LPA allocated time to prepare this report for delivery. Based on the information received during this visit today, there are two (2) deficiencies with Civil Penalties issued for $500 that is being cited per Title 22, Division 6 of The California Code of Regulations. This report, 809 D, LIC421IM and Appeal Rights was reviewed with and a copy provided to the facility representative.