Routine inspection·July 29, 2025

License Program Analyst (LPA) Hansen arrived unannounced at 8:15AM to conduct an annual inspection of the facility. LPA met with staff/designee Danielle Nunez as Licensee/Administrator Kelly Sturgeon was not available. Facility is single story with 5 bedrooms that has a fire clearance by the Petaluma Fire Department granting 6 Non-Ambulatory of which 1 may be bedridden (rm 4). Hospice waiver granted for 4 residents. There is a total of 6 residents, 3 with a diagnostic of dementia. There is 1 resident currently on Hospice. LPA toured the facility on 7/29/2025 at 8:30 AM with designee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices. Fire Extinguisher was found to be last charged on 3/22/2025 at the time of the visit. Smoke detectors & combination carbon monoxide were found to be operational during the visit. Hot water temperature measured between 110.3 degrees F and 112.1 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility on 7/29/2025. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of nonperishable and 7-day supply of perishable 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. Facility oven and stove have protective mechanisms of buttons that must be held for over 5 seconds before heating element will turn on to prevent burns or fire, as per Title 22 regulations. Toxins are stored in a locked cabinet in the kitchen and under locked bathroom sink cabinets. Sharps are kept in locked kitchen drawer. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied hand soap dispensers. Bathrooms contained necessary grab bars and slip-resistant mats, strips, or flooring in all bathtub and or shower floors as required by Title 22 Regulations. All bedrooms have lighting & appropriate furnishings. Continue on LIC809-C Continued from LIC809 A review of six resident & four staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 9:00 AM and learned that 6 of 6 residents have an updated re-appraisals/needs & care plans and physician’s assessments (LIC 602A) were complete. LPA reviewed a sample of staff records at approximately 10:00 AM 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. Direct care staff annual training requirements for 2024/2025 are on file. LPA was presented with proof of CPR & 1 st Aid certification for staff that files were reviewed. Kelly Sturgeon Administrator Certificate # 7007364740 expires on 1/5/2027. Medications were centrally stored in locked cabinet in the facility office area between kitchen and dining room. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 7/29/2025 at 8:45 AM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. Activities of; live ukulele player 2 times a week & accordion player 2 times a month, along with an art teacher instructs 2 times a month as well as exercise classes for range of motion with instructor 2 times a week. Facility recently went to Armstrong woods for the day jointly with some families. Disaster Drills are conducted quarterly with the last one being conducted on 7/12/2025. There were no deficiencies cited at this time. LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 8/15/2025: LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (if changed) LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurance