Routine inspection·September 18, 2025

At approximately 09:45 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and was greeted by caregiver Mark Kho who has Designation of Facility Responsibility (RP) who called licensee/administrator Anny Camerino, who arrived at 10:10 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with four (4) residents in care, three (3) of which are present and one (1) away at day program. Facility is vendorized with the North Bay Regional Center (NBRC). At approximately 10:20 AM, LPA initiated a tour of the facility with Licensee and observed the following: Facility is a one story home, was a comfortable temperature, without odors and passageways were free from obstructions. Water temperatures in Residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, paper products, and incontinent care briefs available to residents. Residents' bedrooms were inspected and observed to be clean, have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods. LPA observed one (1) instance of expired canned food and a technical violation was issued. LPA observed an emergency water supply, as well as, a 124 serving of emergency dry food. Medications were centrally stored and locked. There is a covered seating area in the backyard with outdoor space for activities. LPA observed the locked contents of sheds on either side of the house to be full of additional care supplies and tools. Licensee states that each resident has their own internet access device. Facility has internet available to residents in care and the phone was tested an operational. Facility's fire extinguisher was observed charged and was last serviced 08/2025. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills with the most recent drill conducted 09/2025. Continued on LIC809-C... Continued from LIC809... LPA observed facility's infection control plan and emergency disaster plan which was last updated 09/17/2025. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights for emergency preparedness. At approximately 12:45 PM, LPA reviewed four (4) staff files and four (4) resident files. Two (2) of four (4) staff files reviewed were missing required documentation; Staff 1 (S1) was missing proof of health screening by an MD; Staff 2 (S2) did not have a health screening on site for LPA review and licensee was reminded of the requirement to have all resident and staff records on site for review (See LIC809D and repeat penalty). All staff have proof of current First Aid and CPR training. Licensee did provide evidence of initial 40 hours/20 hours annual training. One (1) of four (4) resident files reviewed were missing required TB screening (see LIC809D) Licensee/Administrator coordinates medical and dental visits for the residents and takes them to their appointments. Facility does not manage P&I monies. Updated copies of the following documents are to be submitted to CCL by 10/17/2025 LIC500 - Personnel Report (updated) LIC9020 Registration of Facility residents. LIC610E - Emergency and Disaster Plan (updated) Proof of liability insurance** Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights were given. Exit interview and discussion of two (2) type B violations, one (1) repeat violation and two (2) Technical Violations was conducted with Licensee who voiced understanding and understanding of Plans of Corrections (POCs). Licensee needed to leave before final report could be reviewed and asked that RP sign final reports. Signature on form by RP confirms receipt.