Routine inspection·April 8, 2025

License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual inspection visit of the facility. LPA was welcomed by Licensee/Administrator, Ladana Luellen. There is a total of 3 residents in care, 1 currently on Hospice, 3 with dementia. LPA toured the facility on 4/8/2025 at 1:45 PM with Licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Fire extinguishers were last checked 10/14/2024. Hot water temperature measured between 111.3 degrees F and 112.6 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms while touring facility. Resident bathrooms had required slip resistant mats and grab bars. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the laundry room. Dangerous items were found stored inaccessible to residents with dementia. There was an ample supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. All bedrooms have lighting & appropriate furnishings. Medications were centrally stored in locked cabinet in facility office/kitchen. A review of three (3) resident & two staff records as well as medication audit was conducted. LPA reviewed resident’s files at 2:15pm on 4/8/2025 and learned that all residents have an appraisal or updated re-appraisals/needs & care plan and 3 out of 3 residents physician’s assessments (LIC 602A) are updated as required by Title 22 Regulations on file. Continue on LIC809-C Continued from LIC809 Medications were centrally stored in locked cabinet in the facility kitchen. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 4/8/2025. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. LPA reviewed a sample of staff records at 2:45 PM on 4/8/2025 and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. LPA observed during staff file review that facility has proof on 4/8/2025 at 2:45 PM of direct care staff annual training requirements. LPA was presented with proof of CPR and 1 st Aid certification for Licensee although staff does not have current 1st Aid. (see LIC 9102 Advisory Notes) Ladana Luellen Administrator Certificate # 7004450740 expires on 4/10/2026. Facility’s last recorded disaster drill was not recorded, licensee informed did not remember when, falling out of Title 22 Regulations (see LIC809-D).LPA advised to ensure that disaster drills are conducted quarterly in different shifts and log drill, as well review facility emergency plan to ensure accuracy according to the needs of facility residents. 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 by 4/25/2025: LIC 308 Designated (if changes) LIC 500 Personnel Summary (if changes) LIC 610 Emergency Disaster Plan (if changes) LIC 9020 Register of Facility /Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurance