Routine inspection·August 14, 2025

8/14/2025 Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Required - 1 Year inspection of this Residential Care Facility for the Elderly and met with Administrator, Josephine Mendoza. This single story, 5 bedroom, 2 bathroom building has been approved for 6 Non Ambulatory residents by Vallejo Fire Department and has hospice waiver for 2. There are currently 6 residents in care, 3 Dementia diagnosis, 1 Hospice. There were 2 staff at the time of inspection. At approximately 12:15pm LPA and Administrator toured facility and grounds and observed all required signs posted in common areas. Facility was found to be at a comfortable temperature with all exits free from obstruction. Facility has at least two days supply of perishable and one week of non-perishable foods and items are stored properly. Toxins are stored locked under the sink in kitchen cabinet. Sharps and other dangerous items were inaccessible to residents in care ; although LPA & Administrator observed cleaning supplies and toxins (bleach) on floor of garage with doors unlocked to garage and no audio alarms activated (see pics & LIC809-D) administrator removed items immediately. Hot water temperature measured between 115.7 degrees F and 119.1 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations. All bedrooms have lighting & appropriate furnishings per Title 22 regulations. A review of six resident & five staff records as well as two resident medications was conducted. LPA reviewed resident files at 12:45 PM on 8/14/2025 and learned that 6 of 6 residents have an updated reappraisal/needs & care plan, TB and physician’s assessments on file as required by Title 22 Regulation. Continued from LIC809 Continue from LIC809: Medications were centrally stored in locked closet in living room (with medications pre-poured for 24 hours-see LIC9102TV) overflow of medication in office cabinet. LPA reviewed a sample of staff records at 1:15 PM on 8/14/2025 and learned that all facility staff present and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff at facility have received additional training and had proof of CPR & 1 st Aid certification. Staff (S1) did not have Health Screening or TB results in file (see LIC809-D). At approximately 2:15 pm a sample review of Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. Administrator Certificate for Josephine Mendoza #7005376740 expires 8/14/2026. Fire Extinguishers were found to be last charged 9/11/2024 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Disaster Drills have been conducted quarterly with the last one being conducted on 3/6/2025. Facility is in the process of getting portable generator in case power goes out. LPA received updated sketch of facility indicating master bedroom (3) is shared room. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. LPA Hansen is requesting Licensee to update the following documents and submit by 8/29/2025: LIC 308 Designated (if changes) LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (if changes) LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate