Routine inspection·August 13, 2025

At 9:45 AM on 8/13/2025, 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 asked to meet with the Designated Facility Administrator (DFA). The LPA spoke with the DFA on the phone. The DFA authorized her representative, designated on the LIC308, to assist and accompany the LPA on a tour of the facility and records review. The designated representative arrived at the facility at 10:30 AM. This facility is licensed to serve six non-ambulatory residents. It has a hospice waiver for six residents. Its fire clearance was issued by Oakdale Fire Department Station 27 on 04/10/2024. The census was four residents at the time of this inspection. There was one caregiver on duty. The LPA toured the inside of the house, including four resident bedrooms, the kitchen, two bathrooms, dining room, living 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, including the license, current administrator certificate, personal rights, complaint hotline poster, and ombudsman information. The LPA inspected three smoke detectors, a carbon monoxide detector, and fire extinguisher. The smoke detectors were in the bedroom hallways and were an interconnected system. Staff tested one smoke detector and all three detectors sounded an alarm. Staff tested the carbon monoxide detector and it sounded an alarm. The fire extinguisher was last serviced on 3/28/2025 by Assured Fire Extinguisher Service. The LPA observed documentation of quarterly disaster drills. This report continues on LIC809-C, page 2. Each bedroom contained the required furniture, including bed, bedside table, lamp, dresser, and chair. The bedrooms and their closets were clean, organized, and odor-free. The bedroom hallway had a nightlight and contained storage cabinets with extra linens. One bedroom contained a full bathroom. A second bathroom was located in the bedroom hallway. Both bathrooms contained grab bars and non-slip mats. Both bathrooms were clean and odor-free. The LPA measured the water temperature at a bathroom sink, which was 113 degrees Fahrenheit. 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, cabinets, and pantry. Sharp objects were kept locked in a lower kitchen cabinet. The LPA observed chemical cleaners in an unlocked lower cabinet under the kitchen sink. Staff stated that the lock was broken. Staff immediately moved the chemicals to a locked staff office. The LPA toured the dining room and living room, which contained enough furniture for all residents, including a dining table and chairs and six recliners. There is artwork on the walls and large windows that let in natural light. The LPA toured the garage. The garage contained an extra refrigerator-freezer, water heater, washing machine and dryer, and storage cabinets. The LPA observed additional perishable food in the refrigerator-freezer and extra supplies for residents in the storage cabinets. The LPA observed chemical cleaners in an unlocked storage cabinet in the garage. Staff immediately locked the access door that led from the house to the garage with a key that only staff had. The LPA toured the back yard, which included a large, wooden shade structure with a table and chairs under it. The concrete patio and walkways on the side of the house are free of obstructions and the surrounding fence is intact and sturdy. This report continues on LIC809-C, page 3. The LPA inspected the central medication storage area. Residents’ medication was kept in a locked cabinet in the kitchen. Each resident’s medication was stored separately in its original containers with intact labels. The LPA observed the electronic-based medication administration record, which was complete and up-to-date. There was a first aid kit in the medication cabinet that contained all the required items. The LPA reviewed records for four residents and two staff and found the records to be complete. Both staff had criminal background clearances and current first aid/CPR certifications. The Administrator’s certificate was valid (#7026256740) and expires 2/14/2027. The LPA requested that updated copies of these documents be submitted to Licensing by 8/27/2025 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 As a result of this annual visit, one deficiency was cited (see LIC809-D). The facility was not in compliance with Title 22 Regulation. An exit interview was conducted with the designated staff and a copy of the LIC 809, LIC 809-D, and appeal rights were provided to the facility.