Routine inspection·September 16, 2025

On 09/16/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required 1 year inspection visit. LPA met with caregiver Leah Slavador and explained the purpose of today's visit. There are currently 3 staff present and 5 residents in care. This is a single level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory and one bedridden. License is approved for 3 hospice residents. There is 1 resident on hospice as of this visit. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. There are no video cameras on site. LPA observed the facility kitchen which is observed as in good working condition. Knives are stored and locked in a drawer adjacent to the sink. There is a locked cabinet beneath the kitchen sink but no cleaning supplies are present when observed. Perishable and non-perishable food supplies are observed as in place. There is an additional cabinet in the garage which stores additional canned goods and dry goods for resident and staff use. First aid kit is observed as complete with required items stored in the medication cabinet which is observed to be locked. LPA observed at least two fire extinguishers in place which are currently within operating range, combination smoke/carbon monoxide detectors are observed in place through out the facility, and central heating. A carbon monoxide detector in place located in a hallway was tested but it did not work. This is a repeat from the 2024 inspection and poses a potential health and safety risk. The facility had combination carbon monoxide/smoke detectors in place that did work according to staff. PPE is observed to be in place. Emergency exit routes are observed inside and outside to be free and clear of obstructions. LPA made observations of the exterior and observed items stored beneath the raised wooden walkway such as old bed frames, trash bags filled with items, walkers, bed cushion, plastic drawers and shelves. The raised wooden walkway is considered as part of the emergency exit route and a bedframe is observed on this walkway leaned against the wall and there is a hole in one of the boards posing an immediate health and safety risk to staff and residents in care in the event of an emergency. Continued on next... Page 2 Along the north side of the facility LPA observed unused washer and dryer, postural equipment, box of clothing/shoes, unused bicycle covered heavily with spider webs, and unlocked paint cans are observed, crawl space screen is also observed as missing and it large hole. The paint cans pose an immediate health and safety risk to residents in care. Water temperature was measured in a resident bathroom at 120F. Cleaning supplies are observed to be locked in the garage primarily. LPA did observe several items as not in good repair during the inspection such as: broken carbon monoxide detector did not function when tested in the hallway central to resident room towards the front of the facility which was also expired as of 08/05/2013, bathroom sink does not fully drain but a plumber is coming to repair the clogged drain but the sink does work. LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Linen closet is observed as stocked with such items for resident use. Shower floors are equipped with non-skid mats or flooring as observed. Facility does not handle resident monies. Medications and logs are observed today as current. During today's inspection LPA reviewed 5 resident files and 3 staff files. LPA observed that S1 was not associated and did not have a finger print clearance on file with department and does not have a TB clearance that can be reviewed. This poses and immediate health and safety risk to residents in care. Administrator certificate is current expiring 07/06/2026. The following updated forms are requested to be submitted to CCLD by 09/23/2025 : • Copy of administrator certificate • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC402 Surety bond information with expiration date • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule Citations are issued on this day on the attached LIC809D pages. Civil penalties are assessed during today's visit attached to this report. $100 x 2 citations = $200 and $1000 x 2 repeat citations = $2000. Report is reviewed with caregiver Leah Salvador and a copy is provided.