Routine inspection·July 15, 2025

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator / Licensee Representative, Marebeth Mallare arrived shortly after and the reason for the visit was explained. Entrance interview. The LPA and staff 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. COMMON AREAS: This includes the family room, TV room, and dining room. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 1:41 p.m., hardwire combination of smoke / carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 01/15/2025. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 06/18/2025 and are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. Adjacent to the dining room is an open office where locked files are located. LPA observed surveillance cameras installed in the common areas of the facility. The Administrator presented the live monitoring screen to the LPA, confirming that all cameras were functioning properly and that none of them were equipped with audio capability. Report Continued on LIC 809-C PAGE 2 ... (PAGE 2) Report Continued from LIC 809-C... INTERVIEWS : Starting at 10:28 a.m. one (1) staff and two (2) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit. BEDROOMS: There are six (6) total bedrooms in the facility; four (4) bedrooms are designated as private, single occupancy, resident rooms and two (2) staff rooms. The staff rooms are kept locked at all times and observed to be occupied by staff. Two (2) out of four (4) resident rooms have exits to the exterior. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. BATHROOMS : There are four (4) total restrooms. One (1) is designated as a shared / common resident restroom, One (1) is designated as a private resident restroom, One (1) is designated as guest bathroom, and one (1) is designated as a staff restroom. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the bathrooms. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured all resident bathrooms and ranged between 105.6-116.1 degrees Fahrenheit, all within the required range. LPA observed storage space closets in hallway containing clean linens for resident use. KITCHEN: The LPA inspected the kitchen/food service area at 10:44 a.m. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 118.6 degrees Fahrenheit at 10:45 a.m. Cleaning supplies and other chemicals are kept in the laundry room locked and inaccessible to residents in care. LAUNDRY ROOM: LPA observed the locked laundry room adjacent to the kitchen. Laundry room has a washer and dryer and locked cleaning supplies. Staff rooms and staff bathroom are accessed through the laundry room. BACKYARD: The entire property is fenced. The backyard has a covered patio area with shade, patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed two (2) self-latching gates. There were no bodies of water noted at the time of the visit. There is a locked storage shed in the back yard inaccessible to residents. Only 1 (one) pathway is used as an emergency exit which was free of obstructions at the time of the visit. Report Continued on LIC 809-C PAGE 3 ... (PAGE 3) Report Continued from LIC 809-C PAGE 2... RECORDS: Record review began at approx. 11:10 a.m . Resident Records were reviewed beginning at 11:11 a.m. and Personnel Records at 12:11 p.m. Three (3) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Four (4) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. At 12:15 p.m. record review revealed that Staff #1 (S1) who was listed on the staff roster -LIC 500 provided to the LPA during the visit was not associated to the facility and they were not listed on the Licensing Information System (LIS) report. LPA checked Guardian and did not observe S1 associated to the facility which poses/ posed an immediate health, safety or personal rights risk to persons in care. An immediate $500.00 civil penalty was assessed. At the time of the visit Administrator submitted documentation to CCL and the staff was associated to the facility. Infection Control / Emergency disaster planning : During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control and emergency planning are satisfactory. MEDICATIONS: Medications review began at approximately 4:05 p.m. Medications are centrally stored and locked in a cabinet in the dining room adjacent to the kitchen. Medications for two (2) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review. Documents obtained during the visit include: LIC 500 facility roster and LIC 9020A Resident roster. The facility was unable to produce a copy of their liability insurance which is in violation of HSC 1569.605. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty was issued in the amount of $500. Administrator was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.