Routine inspection·July 22, 2025

License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required – 1 yr. visit of the facility. LPA was welcomed by Licensee/Administrator Doug Cattich. Facility is a single story 9 bedroom (1 staff & 1 double) RCFE that has a fire clearance for 9 Nonambulatory residents, of which 1 may be bedridden. There is currently a total of 7 residents, 5 with a dementia diagnosis and no currently under Hospice services. LPA toured the facility on 7/22/2025 at 8:45 AM with Licensee/Administrator Doug Cattich; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices, and doors were activated at the time of the visit. Hot water temperature measured between 107.2 degrees F and 114.4 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 5 of 5 resident’s bathrooms while touring facility on 7/22/2025 at 9:10 AM. 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 foods 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 of the facility. Dangerous items are stored inaccessible to residents with dementia. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, although main bathroom where showers are given does not have slip-resistant mats, strips, or flooring in shower floor as required by Title 22 regulations. Facility was given TA during last years inspection for this issue on 7/25/2024 (see pics & LIC809-D). All bedrooms have lighting & appropriate furnishings. Receipt posted of pest control service, per Licensee monthly, last conducted 6/3/2025. Continued on LIC 809-C Continued from LIC809: Facility is missing 5 window screens that need to be replaced (see pics LIC809-D). A review of seven resident & five staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 10:00 AM on 7/22/2025 and learned that 7 of 7 residents have an updated reappraisal/needs & care plan, TB and physician’s assessments on file as required by Title 22 Regulation. At approximately 11:15 AM LPA reviewed a sample of staff records 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 the facility have received the additional training required. LPA was presented with proof of CPR & 1 st Aid certification for staff that files were reviewed. Doug Cattich Administrator Certificate # 7002018740 expires on 8/11/2025. Medications were centrally stored in two locked cabinets in the facility kitchen. At approximately 12:00pm LPA conducted sample review of 2 out of 2 residents medications, which were found to be given according to physicians’ directions on 7/22/2025. However, residents medications have been 24 hour pre-poured and new regulation 87465(h)(5) states No medications shall be transferred between containers. (see LIC 9102 Advisory Notes) Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. In addition. Fire Extinguisher was found to be last charged on 6/26/2025 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Fire sprinkler inspection conducted 7/2025 indicated several deficiencies for gauge on sprinkler riser expired, bell sign faded, spare head box needs replacement quick response heads older than 20 yrs require UL testing prior to replacing new heads, and other items that require action to ensure continued safety and functionality of the fire sprinkler system. LPA requesting update once corrected. Disaster Drills have been conducted quarterly with the last one being conducted on 6/10/2025. Facility has portable generator in case of emergency & power goes out. Facility’s backyard has been under construction for the last month due to rebuilding of patio (see pics) and per Licensee should be completed by end of summer. LPA discussed plan of keeping residents safe from the rusted wire sticking up from the ground until cement is poured and construction complete. Continue LIC809-C2 Continued from LIC809C: 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 and submit the following documents by 8/8/2025 to CCL/SRRO: LIC 308 Designation of Facility Responsibility LIC 500 Personnel Record LIC 610 Emergency Disaster Plan (if changes) LIC 9020 Residents Roster Copy of Administrator Certificate Proof of Liability Insurance Proof of corrections to Fire Sprinkler System (due 8/15/2025)