Routine inspection·August 13, 2025

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 11:17 A.M. The LPAs met with Licensees Teresita and Larry Wayne and discussed the reason for the visit. At the time of the visit the facility has only one (1) resident. The administrator stated that they intend to close the facility and are seeking to have Resident #1 (R1) relocated. The LPA, along with facility Licensee Larry Wayne, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers were observed to be fully charged but purchased on 08/06/2024. At 1:25 P.M. hardwired smoke detectors and a separate carbon monoxide detector were tested and were functional at the time of the visit. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, the living room and dining room furniture was observed to be in good condition. The LPAs observed the required postings in the common area. The backyard was observed to be cluttered with multiple objects blocking emergency exit, however, the licensee stated that R1 does not utilize that area. There were no bodies of water noted. The garage was observed locked and is also used as a storage room. Continued on LIC 809-C Continued LIC 809 KITCHEN : Kitchen appliances appeared to be in operable conditions. The facility has a sufficient supply of perishable, non-perishable food, emergency water and emergency food. All sharp objects were observed to be locked and properly stored at the time of the visit. At 1:25 P.M. hot water measured at 114.9 degrees Fahrenheit. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 1 (one) is currently occupied for resident use, three (3) were being used for storage, and one (1) was designated as a staff room. RESTROOMS: The LPAs noted there are 2 restrooms in the facility; one is designated for resident use, and one is for staff use. LPAs observed the resident restroom. The resident restroom was clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. At 1:28 P.M. hot water measured 113.9 degrees Fahrenheit. RECORD REVIEW: Beginning at 12:40 P.M., staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Review of R1’s record revealed missing required documentation, including a needs and service plan, physician’s report, consent forms and face ID sheet. Review of two administrators’ files showed that both administrators’ certificates were expired at the time of the visit. Last emergency drill was not documented. Liability insurance is expired. The last Emergency Plan and Infection Control Plan were not provided (Technical Violation issued). MEDICATION REVIEW: Beginning at 1:32 P.M., LPA Dulek reviewed medications for R1. Prescription medications appeared to be maintained and administered in compliance with regulation. The facility is using the centrally stored medication records, however, did not have August medications documented. Continued on 809-C Continued from LIC 809-C INTERVIEWS: During today's visit LPAs interviewed R1. The facility does not have a caregiver to interview only the administrators who were interviewed. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies and civil penalties were cited (refer to LIC 809-D). Exit interview conducted. A hard copy of the report and appeal rights were provided.