Routine inspection·June 13, 2025

Unannounced Annual visit made out to this facility on 06/13/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, Nicole Ell, who was briefly interviewed at this time. Current census was 4 residents, of which (3) residents, were out of this facility attending their respectable day programs at this time. It was learned that (1) resident was out of this facility at the hospital at this time. It was learned that there weren't any residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (6) residents under the care of hospice at any given time. It was learned that this facility does have a program to be able to accept and retain dementia residents at any given time. It was learned that there were (2) residents diagnosed with dementia at this time. It was learned that there weren't any residents receiving services through home health at this time. It was learned that there weren't any residents deemed to be bedridden at this time. Tour of this facility was conducted. Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet, located in facility restroom, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time. Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured. Additional food storage units located in the laundry room were observed to be present and functional at this time. Laundry room was toured at this time. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Administrator certificate, # 7005838740, for Nicole Ell was observed to have an expiration date of 08/16/2026 and in compliance at this time. Forms and documents were being updated in order to renew this Administrator certificate at a later time. Medication cabinet, located in the facility laundry room, was observed to be locked and made inaccessible to the residents at this time. First aid kit, located in the laundry room, was reviewed. This LPA observed that it did contain all of the required components at this time. Fire extinguishers were located in the kitchen area and laundry room and observed to have been annually inspected by the local fire extinguisher company, Assured Fire Company, on 03/18/2025 and found to be in compliance at this time. Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted. A review of (5) facility personnel records was conducted and noted on the following LIC 859. A review of (4) facility resident records was conducted and noted on the following LIC 858. The following forms and documents were requested to be updated and submitted into CCL for review by this LPA: LIC 308 LIC 400 LIC 500 LIC 610 The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal rights were printed and a copy was given to the facility designated Administrator at this time. Exit Interview