Routine inspection·April 22, 2025

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required inspection and met with Licensee, Laarni Lockerbie & Administrator, Armela Marie Monte. Facility is single story with 5 bedrooms & 3 bathrooms with an approved Fire clearance for 6 Non-Ambulatory residents & Hospice Waiver for 2. There is a total of 5 residents, 1 under hospice care & 3 with diagnosis of dementia. LPA initiated a tour of the facility at approximately 8:25 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Cleaning supplies and toxins observed in locked cabinets in garage & under kitchen sink not accessible to residents in care. Resident’s rooms were furnished per regulation. Water temperature in bathrooms measured at 118 degrees F and 121.2 degrees F, not within the range of 105 to 120 degrees F allowed per regulation; although Administrator provided proof new water heater was just installed prior day and is adjusting (LIC9102 TA). Resident bathrooms had required slip resistant mats and grab bars. Extra hygiene products and linens were available. Cabinet containing cleaning supplies in garage was locked. There was enough lighting in all common areas, resident rooms, and hallways. Fire extinguisher was last inspected 3/4/2025. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. At approximately 9:15 AM, LPA reviewed 5 of 5 resident records and found 5 of 5 residents have current physician’s reports or care plans. 5 of 5 resident records contained current and signed admission agreements and physician’s orders on file. Continue on LIC809C Continue from LIC809: Medication records are thorough and contained physician’s orders for each resident. At approximately 10:30 AM, LPA review 4 of 4 staff records. 2 of 4 staff records (S1 & S2) only contained 12 of required 20 annual completed training as required (see LIC809D). Evidence of current first aid and CPR training were observed. 4 out of 4 staff have required Health Screening records. Medications were centrally stored in locked cabinet in the facility living room. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 4/22/2025 at 12:30 PM. At approximately 12:45 PM, LPA reviewed the facility emergency disaster plan with staff. Facility does not have a generator to supply power during an outage. Administrator informed they are currently deciding how to handle emergency outages with residents on oxygen and other electrical issues (see LIC9102 TA) The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts disaster drills quarterly and documented last disaster drill on 2/24/2025. Administrator Certification for Armela Marie Monte #6071239740 expires 07/08/2026. Appeal Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided. LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 4/30/2025: LIC 308 Designation of Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (if changes) LIC 9020 Register of Facility /Resident’s Copy of Lease Agreement Proof of Liability Insurance