Routine inspection·October 30, 2025

On 10/30/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required 1-year annual inspection. LPA was greeted by a staff member. LPA Lindstrom introduced herself and explained the purpose of the visit. The Care Coordinator arrived at the facility at 1:00 PM and an interview followed. The Care Coordinator joined the LPA on a tour of the facility. The facility is licensed for a capacity of six, including six non-ambulatory only, with a hospice waiver for two. The census at the time of this site visit was five. The Administrator had an Administrator’s Certificate (#7002348740) that wa valid through 12/16/2025. The two Caregivers on duty had criminal background clearances; one of the two caregivers was not associated with the facility. The LPA toured the interior of the facility. The entire facility is clean, orderly, and odor-free. The interior is decorated and filled with natural light. The LPA observed the required postings on the wall near the entry. The living room, dining room, and family room contained adequate seating for residents. The LPA observed three residents in the living room that were reading, watching television, or socializing with family. The bedrooms were clean and contained the required furniture. The windows and window screens were intact. The bathrooms were clean and odor-free. The water temperature in the hallway bathroom was 108 degrees Fahrenheit, which is within the required range of 105 - 120 degrees Fahrenheit. The bathrooms contained grab bars and non-slip mats in the showers. There were extra towels, linens, and supplies in the hallway cabinets. The thermostat was set at 73 degrees Fahrenheit. Staff tested the smoke and carbon monoxide detectors, which were in working order. The fire extinguisher was serviced on 2/19/2025 (Continued on LIC809-D) by Touchdown. The LPA observed logs of quarterly fire drills and an emergency disaster plan that had been reviewed in 2025. The LPA toured the kitchen. The kitchen was clean, orderly, and odor-free. There was a two-day supply of perishable food and seven-day supply of non-perishable food in the refrigerator/freezer and pantry. The LPA observed sharps locked in a kitchen drawer and cleaners locked in a cabinet under the sink. The LPA toured the laundry room. Cleaners and extra toiletries were locked in cabinets in the laundry room. The LPA toured the garage and observed extra food in a chest freezer and refrigerator. The LPA inspected the central medication storage. Medication was stored in locked cabinets in the kitchen, separate from the food. The LPA observed that resident medication was stored in its original containers with intact labels. A first aid kit was located in this cabinet that contained all the required items. The LPA reviewed the paper-based medication administration records (MAR) and found it complete and up-to-date. The LPA inspected the grounds. The backyard was manicured and enclosed by a fence. The walkways were free of obstruction. The LPA reviewed three staff files and five resident files. All staff and resident files were complete. The LPA requested that updated copies of the following documents be submitted to Licensing by 5:00 PM on 11//2025. These documents can be emailed to theLPA at ellen.lindstrom@dss.ca.gov. (1) LIC 308 Designation of Facility Responsibility (2) Copy of a current Administrator Certificate (3) LIC 610 Emergency Disaster Plan (4) Proof of Liability Insurance (5) LIC 500 Personnel Report (6) LIC 309 Administrative Organization (Continued on LIC809-D) As a result of this inspection, a deficiency was cited. The facility was not in compliance with California Code of Regulations (CCR), Title 22, Division 6. The deficiencies are listed on the attached LIC 809D. Failure to correct deficiencies by the noted due date may result in the assessment of civil penalties. An exit interview was conducted with the Care Coordinator, to whom a copy of this LIC809 report, the LIC809D, and the appeals rights was provided. Their signature below confirms receipt of this document.