Routine inspection·July 8, 2025

On July 08, 2025, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the caregiver, Elsa Lopez, and disclosed the purpose of the inspection. The caregiver informed the LPA that the facility had five (5) residents in care and three (3) staff members present at the time. At 8:45 AM, the LPA initiated a walk-through of the facility, accompanied by the caregiver. LPA inspected the kitchen and found it clean, with breakfast preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. LPA inspected a locked cabinet containing knives and sharp objects, and a locked cabinet under the sink that stored detergents and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for two (2) days and nonperishable staples for seven (7) days were observed. No expired food or stored medications were noted. LPA inspected the dining area adjacent to the kitchen and found it clean. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. The LPA observed two (2) residents eating breakfast at the dining table. LPA inspected the living room and observed it to be clean, with all furniture in good repair. There were sofas, a recliner chair, and a television in the living room. LPA observed one (1) resident watching TV in the living room. LPA inspected the fire extinguisher mounted on the wall in the living room and found it fully charged, with the last service tag dated 08/05/2024. The caregiver tested the smoke and carbon monoxide detector located in the hallway in LPA’s presence, and it was found to be functional. Continued on LIC809-C Additional smoke detectors were observed in all bedrooms and common areas of the facility during the visit. There were five (5) bedrooms and three (3) bathrooms designated for residents’ use. Four (4) rooms were single occupancy and one (1) room (#2) was a shared occupancy. At 9:10 AM, LPA inspected all five (5) resident rooms and found them clean, well-lit, and equipped with the required furniture. LPA observed a bedridden resident (R1) in shared room #2. R1 was not on hospice. Room #2 did not have an approved fire clearance for a bedridden resident. Only room #4 had an approved fire clearance for a bedridden resident. LPA observed that R3 used a Foley catheter, but there was no restricted health condition exception applied for or granted for the catheter use. LPA inspected three (3) full bathrooms and found them clean, sanitary, and in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower chair, and non-slip mats. The hot water temperature at the sink faucet measured 115.3°F in bathroom #1 and 115.8°F in bathroom #2. LPA inspected the two (2) storage closets in the hallway and observed that they contained clean linens, blankets, and towels for residents’ use. LPA inspected the garage. A washer, a dryer, and closets containing incontinence supplies, cleaning solutions, and paper products were observed. LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. No bodies of water were noted. LPA inspected two (2) storage sheds and observed wheelchairs, furniture items, bedframes, mattresses, outdoor furniture, outdoor heaters, and suitcases stored in the sheds. LPA reviewed six (6) staff personnel records and five (5) resident records. LPA observed that five (5) of five (5) residents had an Admission Agreement, Physician's Report, Appraisal/Needs and Services Plan, and CSDMR. LPA observed that six (6) of six (6) staff members had current First Aid certificates, LIC 508 Criminal Record Statements, and LIC 503 Health Screenings, and confirmed that five (5) of five (5) staff members were associated with the facility. LPA observed a locked centrally stored medication cabinet located in the dining area. Medications were organized separately for each resident. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete. Continued on LIC809-C LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 06/07/2025. The following updated forms are requested to be submitted to CCLD by 07/15/2025: LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility LIC 999: Updated Facility Sketch Certificate of Liability Insurance Administrator Certificate(s) Current Property Lease Agreement The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, and Plans of Correction were reviewed and developed with the caregiver. A copy of this report and appeal rights were discussed and left with the caregiver, Elsa Lopez, whose signature on this form confirms receipt of these documents.