Routine inspection·August 21, 2025

At 10:20 AM on 8/21/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by a caregiver. The LPA identified herself, explained the purpose of the visit, and requested to meet with the Administrator. A caregiver called the Administrator to inform her that the LPA was on site to conduct an annual inspection. The Administrator arrived at the facility at 10:30 AM and an inteview followed. The Administrator accompanied the LPA on a tour of the facility. This facility is licensed to serve six non-ambulatory residents and has a hospice waiver for six. The facility is a five-bedroom, 2-bathroom house located in a residential area. The census was four residents at the time of this site inspection, all of whom were at the facility at the time of the site inspection. There were two staff on duty when the LPA arrived at the facility. The LPA toured the inside of the house, including the bedrooms, bathrooms, kitchen, dining room, living room, laundry room and garage. The entire house was clean, odor-free, and pest-free. The windows and window screens were in good repair. The required documents were posted in the entry way and front room. The LPA toured the four resident bedrooms and one resident bathroom. There are two double-occupancy bedrooms and two single-occupancy bedrooms. Each bedroom contained the required furniture, including bed, bedside table, lamp, dresser, and chair. The LPA toured the bathroom. The bathroom contained grab bars, non-slip surfaces, and assistive devices. The LPA measured the water temperature at a bathroom sink. The temperature of the water was 120 degrees Fahrenheit, within the required range. The Administrator stated that staff tested the water temperature daily. (Continued on LIC 809-C) The LPA toured the kitchen. The kitchen was clean, the appliances were operable, and the trashcan had a lid on it. There was a seven-day non-perishable and two-day perishable supply of food located in the kitchen refrigerator-freezer and cabinets, as well as a refrigerator-freezer and storage container in the garage. There were flashlights in a kitchen drawer. The LPA observed that the drawer in the kitchen containing sharp objects was unlocked. The LPA toured the dining room, living room, and hallway. The LPA observed a table and chairs in the dining room and a large couch in the living room that provided adequate seating for residents. There is a large TV in the living room. The LPA observed a fire extinguisher in the living room. The fire extinguisher was purchased on 9/4/2024. The fire extinguisher had never been used and was in the green. The LPA observed that the thermostat in the hallway displayed 79 degrees Fahrenheit. There were two smoke detectors and two carbon monoxide detectors in the hallway. The Administrator tested the smoke and carbon monoxide detectors and all were in working order. There were cabinets in the hallway that contained linens, resident care supplies, personal protective equipment, and a first aid kit. The first aid kit contained all the required items. The LPA toured the laundry room and garage. The laundry room contained a washing machine and the staff bathroom. The LPA observed chemical cleaners in a cabinet above the toilet and a cabinet beneath the sink that were not locked. The garage contained the dryer and storage cabinets with incontinence care. The LPA toured the front, back, and side yards. The LPA observed a shaded table and chairs in the backyard. The backyard lawn was manicured, and the backyard was enclosed with a wooden fence that was sturdy and intact. The LPA inspected the central medication storage area. Resident medication and medication records were stored in a locked cabinet in the front office. Each resident's medication was stored in a separate container and all medication was in its original packaging with intact labels. (Continued on LIC 809-C) The LPA inspected the paper-based medication administration record (MAR) and three medications for one resident (R1). The LPA observed that one medication bubble pack had one dose missing from it, but the medication was not listed in the MAR. There was no record of when the medication was administered. The LPA observed that another medication bubble pack had many doses missing from it. This medication was listed in the MAR but there were no staff signatures indicating when it had been administered. The LPA reviewed records for two residents and two staff and found the records to be complete. Both staff records contained criminal background clearances, current first aid/CPR certifications, and TB tests. Both resident records contained health screenings, TB tests, admission agreements, and care plans. The LPA requested that updated copies of the following documents be submitted to Licensing by 8/29/2025 at ellen.lindstrom@dss.ca.gov. (1) LIC 308 Designation of Facility Responsibility (2) Copy of a current Administrator Certificate (3) LIC 610D Emergency Disaster Plan (4) Proof of Liability Insurance (5) LIC 500 Personnel Report (6) LIC 309 Administrative Organization As a result of this inspection, no deficiencies were cited. The facility was in compliance with the California Code of Regulations (CCR), Title 22, Division 6. An exit interview was conducted with the Administrator, to whom a copy of this LIC809 report, the LIC 809D, and the appeals rights was provided. Their signature below confirms receipt of this document.