Routine inspection·October 14, 2025

On 10/14/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required 1-year annual inspection. LPA was greeted by two Caregivers. LPA Lindstrom introduced herself and explained the purpose of the visit. A Caregiver called the Administrator, who arrived at the facility at 12:15 PM and an interview followed. The Administrator joined the LPA on a tour of the facility. The Administrator has an Administrator’s Certificate (#7025797740) that is valid through 6/25/2027. The three Caregivers on duty at the time of the site visit had criminal background clearances and were associated with the facility. The facility had five bedrooms and three bathrooms. The current census is five residents. 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 living room, dining room, and family room contained adequate seating for residents. 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 117 degrees Fahrenheit. The bathrooms contained grab bars, a trashcan with a lid, and non-slip mats in the showers. There were extra towels, linens, and supplies in the hallways in the closet. The thermostat was set at 77 degrees Fahrenheit. The smoke and carbon monoxide detectors were in working order. The fire extinguisher was serviced on 2/20/2025 by Touchdown. The LPA observed logs of quarterly fire drills and an emergency disaster plan that had been reviewed in 2025. (Continued on LIC809-D) 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 kitchen cabinets. Sharps were locked in a kitchen drawer. The LPA toured the laundry room. Cleaners were locked in a cabinet in the laundry room. The LPA toured the garage and observed extra food in a refrigerator and freezer, and extra supplies in cabinets. The LPA inspected the central medication storage. Medication was stored in a hallway closet. The LPA observed that resident medication was stored in its original containers with intact labels.A first aid kit was located in this closet 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 front yard had ornamental plantings and a fenced activity area with table and chairs. The backyard had two shaded areas with tables and chairs. The walkways and the exit gate were free of obstruction. The LPA reviewed three staff files and four resident files. One resident had a medical assessment that did not include a TB test. One staff file did not include a health screening with TB test results or a first aid certificate. The LPA requested that updated copies of the following documents be submitted to Licensing by 5:00 PM on 10/28/2025. 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 As a result of this inspection, deficiencies were 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 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.