Routine inspection·August 19, 2025

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's requires - 1 year annual inspection. LPA met with Administrator, Armando Guba. During visit, LPA toured the facility to include the resident bedrooms, bathrooms, living room, kitchen, garage and backyard. All fire exit routes were free and clear of obstruction. There were 2 staff present to 3 residents. 2 out of 3 residents are under hospice care. The 2 staff present are fingerprint cleared, but 1 out of the 2 staff are not associated to the facility. Administrator admitted that 1 staff member was not associated to the facility as the staff was added to the schedule last minute. The Administrator immediately submitted the LIC9182 form to the Department to associate the staff to the facility roster. A technical violation was provided per Section 87355(e)(3) reminding the facility to ensure all staff working are requested a transfer of a criminal record clearance prior to work. Facility temperature maintained at 78 degrees F. Fire extinguisher last serviced on 08/01/2025. Emergency lighting observed in the hallway. Smoke detector and carbon monoxide detector was tested and observed operable. Bathroom hot water temperature maintained at 117.8 degrees F. The bathroom shower observed with non-slip mats and grab bars. Facility has at least 2 days worth of perishables and 7 days worth of non-perishables foods. Refrigerator temperature maintained at 35.6 degrees F. Freezer temperature maintained at -4 degrees F. Page 1 of 4. Sharp objects, chemicals, disinfectants, and medications were not locked during the visit but the staff was present in the kitchen area. LPA advised the staff to ensure these items are locked when staff leave the area. Staff immediately locked the cabinets and drawers during visit. Resident bedrooms equipped with proper furniture, lighting, night stand, and dresser. 1 resident who is under hospice care observed using oxygen. Oxygen in use sign observed posted on the door. 1 resident (R1) bedroom observed with full bed rails. The resident is not under hospice care. Based on review of the facility's file, the facility did not submit any exception regarding the use of full bed rails. LPA reviewed the resident's records and did not observe a physician's order for the full bed rails. LPA observed a letter from the resident's responsible party supporting the use of full bed rails as the resident is fall risk. Administrator was advised of Title 22 regulation Section 87608. A type A deficiency was cited today per Section 87608(a)(5)(B) wherein 1 resident who is not under hospice care is utilizing full bed rails without prior approval from the Department. LPA observed the garage is being used as a sleeping quarters for 2 staff members (S1 - S2). Photographs of the garage were taken. Based on the facility sketch and fire clearance, the garage is not approved to be used as a living quarter for staff. Staff stated there was a total of 3 live-in staff members. The other staff member (S3) is using the living room couch as a sleeping area. A type A deficiency was cited today per Section 87307(a) wherein the live-in staff are residing in the garage and living room which is not related to the facility's functions per the facility sketch. LPA reviewed 3 resident files. 3 out of 3 resident files were not complete and up to date. 3 resident files contained an admission agreement, consent form, personal rights, and identification and emergency contact information. However, 1 resident (R1) did not have a medical assessment on file prior to admission. Resident (R2) has dementia and the last medical assessment was last completed on 09/08/2023. Resident (R3) who was placed under hospice care on 12/27/2024, medical assessment was last completed on 08/08/2022. A type B deficiency was cited today per Section 87463(h) wherein 1 resident did not have a medical assessment on file and 2 resident's medical assessments were not updated within the last 12 months. Page 2 of 4. 2 out of 3 residents did not have a reappraisal completed. 1 out of 3 residents had a reappraisal, however the reappraisal was not signed by the resident and/or resident's responsible party. A type B deficiency was cited today per Section 87463(a) wherein 2 residents reappraisals was not updated as necessary and 1 resident's reappraisal was not signed by the resident/resident responsible party. LPA reviewed 3 residents centrally stored medications and centrally stored medication records. LPA observed that 3 residents centrally stored medication records were not complete as there was 16 medications from R1 - R3 that were not written in the centrally stored medication record (CSMR). A type B deficiency was cited today per Section 87465(h)(6) wherein there was 16 medications from R1 - R3 that was not maintained in the resident's CMSR. LPA observed that that residents require PRN medications at the facility. Based on the facility's record review and confirmed by the Administrator, the facility does not have a PRN log in the resident's records to include the date/time PRN was taken, dosage, and resident's response to the PRN. A technical violation was provided per Section 87465(c)(3). LPA reviewed 4 staff members files. 4 out of 4 staff members has a fingerprint clearance. 4 out of 4 staff members does not have a 1st aid certification. A type B deficiency was cited today per HSC 1569.618(c)(3) wherein 4 staff members does not have a 1st aid certification. 3 out of 4 staff members does not have a TB result. A type A deficiency was cited today per Section 87411(f) wherein 3 staff members does not have a complete health screening to include a TB result on file prior to working in the facility. 4 out of 4 staff members does not have any initial or annual training provided per Title 22 regulations. A type B deficiency was cited today per Section 87411(c) wherein 4 staff members who assist residents with activities of daily living has not received initial and annual training. Page 3 of 4. The facility has not completed any emergency disaster drills. A type B deficiency was cited today per HSC 1569.695(c) wherein the facility has not conducted any emergency drills. The following documents were requested by 08/26/2025 to be sent to the licensing general email to include: LIC500, emergency disaster plan, LIC308, and Administrator certificates. Deficiencies were cited today per California Code of Regulations, Title 22. See LIC809D. Advisory note provided. This report was reviewed with Administrator, Armando Guba and a copy of the report and appeal rights were provided. Page 4 of 4.