Routine inspection·April 14, 2026

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by licensee Ladana Luellen. Administrator certificate #7004459740 expired 4/10/26. However, licensee produced proof of mailing of Admin cert renewal with date stamp of 4/11/26. Facility currently has three (3) residents in care two (2) of which are currently on hospice. At approximately 2:15pm LPA toured the building and grounds. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be open, uncovered, and many items expired. Facility has a pantry in room #3 and food pantry in the kitchen. LPA observed expired food items in both. Expired items include: two 920 boxes of Stove Top expired 9/2/2022, two (2) boxes of Shake and Bake expired 2/9/2016, Betty Crocker Mashed potatoes expired 3/15/2015, sunflower seeds expired 3/4/2019, Jello pudding expired 7/16/2023, Jello gelatin expired 1/19/2019, Mrs. Grass noodles soup expired 8/9/2022, boiled oysters 7/4/2017, sardines expired 12/2024, luncheon loaf expired 3/15/2020, corn muffin mix expired 11/3/2018, salad dressings respective expired 10/30/2024, 3/2022, and 12/22/2021 ( deficiency cited, see 809D ). Freezer item of sausage links and hot dogs were stored open and uncovered in kitchen. Facility also has a freezer in the garage, almost all items in the freezer had ice and ice crystals forming on top and within packages of meat and other items. Open and uncovered was a bag of meat that was fatty and gray in color. LPA observed in pantry in room #3 open bag of grits not sealed or rolled shut, and one container of spicy ranch salad dressing 7/12/2025 and strawberry fruit spread 6/8/2019 open, not refrigerated and stored in pantry closet ( deficiency cited, see 809D ). LPA observed kitchen cabinet under sink to contain bucket to catch water. Sink leaks, per licensee they have to empty the bucket of water once a month. Sink in room #1 has two (2) buckets underneath to catch water. LPA observed water in both buckets as well as bowed/ballooning wood and gray and blue substance Continued on 809C... Continued from 809... present. Facility has three bathrooms: one (1) in resident room #1, one (1) in resident room #3 and a main bathroom in the hallway. Main bathroom has electrical outlet is disrepair ( deficiency cited, see 809D ). Additionally, per licensee resident has been using bathroom in room #3, which is not their room. The bathroom is the first door on the right when entering room #3. LPA advised of regulation 87307(a)(2)(c) which states: No bedroom of a resident shall be used as a passageway to another room, bath or toilet . All bedrooms were equipped with lighting, night stand, chair, but room #2 did not have chest of drawers ( deficiency cited, see 809D ). Window sill in room #3 has many dots of black and gray fuzzy substance (deficiency cited, see 809D ). Extra hygiene products and linens were available. LPA discussed with licensee the use of resident rooms as storage for faclity supplies such a gauze, gloves, chucks, and personal items such as clothes. Room #1 has two large furniture items used to store the licensees' personal items. Additionally, LPA found closets in room #1 and room #3 to be locked, making them inaccessible to residents in care. Closet in room #3 also houses facility supplies. LPA discussed with licensee regulation 87308 pertaining to storage. Resident bathrooms had required bath mats and grab bars. Water temperature in sinks measured at 108.6 degrees F in the kitchen and 107.4 in the bathroom used by residents, both of which are within the allowable range of 105 to 120 degrees F. Facility has another bathroom used by staff only. Fire extinguishers were last inspected 10/22/2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted on 1/25/26. Facility has a backup generator for use during a power outage. At approximately 4:00pm LPA conducted a review of three (3) out of three (3) resident files . R1 did not have TB clearance file ( deficiency cited, see 809D ). At approximately 4:30pm LPA conducted a review of three (3) staff files. Staff S1 and S2 did not have 1st Aid ( deficiency cited, see 809D ), Health Screen with TB clearance ( deficiency cited, see 809D ) , or required training current or on file ( deficiency cited, see 809D ) . Continued on 809C(2)... Continued from 809C... At approximately 5:30pm LPA conducted a review of medication regulations including a PRN MAR requirement and Centrally Stored Medication Log requirements. Facility not using a PRN MAR. LPA discussed with licensee obtained PRN authorization letters for all residents in order to know if a PRN MAR is required for that resident. LA discussed with licensee activities in the facility, especially those suited for residents with cognitive impairment or dementia. LPA did not observe any activities. LPA and licensee discussed Emergency Disaster Plan. Licensee confirmed no updates needed. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given.