Routine inspection·September 18, 2025

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Riley Tucker, Administrator. During visit, LPA Marrufo toured the facility inside and out. LPA toured the hallway bathrooms in the first and second floors. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks were 109 F. LPA observed the first aid kit and found it to be complete. LPA tested the carbon monoxide detector and it functioned properly during testing. During visit, staff tested the smoke detection system and it functioned properly when tested. LPA toured the outside areas and observed the exits to be clear of obstructions. LPA reviewed seven resident Centrally Stored Medication and Destruction Records (CSMDR). Resident R1 was missing two medications in his/her CSMDR. LPA reviewed seven resident records and found them to be complete. LPA reviewed seven staff records. The records of staff S1-S5 were missing the LIC503 Health Screening form. S5 did not have a current first aid certification. The emergency disaster drill log indicates that the last drill occurred on 07/07/2025. See LIC809-C page for more information. Page 1 of 2. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. LPA Marrufo requests that copies of the following documents be updated and sent to the department: LIC500 Personnel Report LIC308 Designation of Administrative Responsibility LIC610E Emergency Disaster Plan This report was reviewed with Administrator Riley Tucker and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORT