Routine inspection·December 9, 2025

On 12/09/2025, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced post-licensing and annual inspection. LPA Lee met with Administrator Shabana Buksh and explained the purpose of the visit. The Administrator Certificate # is 6069964749 and will expire on 05/07/2026. The current census is 1 resident with 1 facility staff. This facility is a single-story building licensed to serve six (6) ambulatory residents only and hospice waiver approved for 2. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room, garage, staff office and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 119.3 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. The smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 09/22/2025. LPA Lee observed the facility has a has a public telephone in the common area. Facility thermostat was observed at 75 degrees Fahrenheit, which is within the required regulation of 68 to 85 degrees Fahrenheit. LPA Lee observed toxins located in laundry and kept locked and inaccessible to residents. LPA Lee observed sharp knives kept locked in the kitchen cabinet and inaccessible to residents. CONTINUED LIC 809-C LPA Lee observed that the entry door and the exit door in the living room that lead to the backyard did not have a single-action mechanism for unlocking and opening. The administrator stated they will remove the secondary lock on both doors to ensure compliance. LPA Lee informed the administrator that all emergency exits must operate with a single-action mechanism. LPA Lee also observed that the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) was in the incorrect size and needs to be in the size of 20" x 26" in size. Administrator stated they will have the Pub 475 enlarge to the correct size and have it posted. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. The first aid kit was checked and contained the required components. LPA Lee reviewed medications for 1 out of 1 resident by comparing the medications on hand with their Medication Administration Records (MARs) and confirmed that all records were accurate and complete. LPA Lee reviewed 1 out of 1 resident file, and it was incomplete. Resident 1 (R1) is missing their TB test. Administrator stated that she will reach out to R1’s primary care provider and the R1’s responsible party to obtain a copy of R1 current TB and should if one is not available ensure that R1 has an appointment to get their TB test completed. LPA Lee reviewed 2 staff files, and it was also complete. The following documents will be email to LPA Lee at pang.lee@dss.ca.gov by 12/16/2025 end of day 5:00 PM. (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610 Current Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) LIC 500 Current Personnel Report As a result of this annual and post-licensing visit , the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with Administrator Buksh and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.