Routine inspection (multi-day)·October 15, 2025

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 10/14/2025. The LPA met with Administrator Rafael Silva and explained the reason for the visit. The LPA conducted a tour of the physical plant with Administrator Rafael Silva to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double story residence, with the second story only for staff use. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 01/23/2025. The smoke alarms and carbon monoxide detectors were tested and functioned properly. KITCHEN: The kitchen is left locked so residents cannot enter. The kitchen was clean and the appliances appeared to be functional The facility's main pantry is air conditioned and located outside. The pantry had non-perishable foods, perishable foods, and three large freezers with perishable foods. Food was also stored in the kitchen and another pantry inside the facility which had more non-perishable food and emergency water. RESIDENT ROOMS: There are currently sixteen rooms available for residents of which ten (10) are being used by residents; these rooms can be shared or can be single rooms. There are two (2) rooms being used as model rooms and one (1) as an activity room. There are six rooms upstairs which are used as office space, staff rooms, and storage. The upstairs rooms can only be accessed by stairs so they are not in use for residents at this time. Rooms housing residents appeared to be clean with appropriate furnishings, bedding and sufficient lighting, however floors needed to be swept. Report will continue on LIC809-C, 2nd page. BATHROOMS: The facility has two shower rooms of which the toilet in one of the shower rooms is not working. Upon observation Administrator stated they would be fixing it by tomorrow 10/16/25. Four resident rooms have full bathrooms. The facility has eleven half bathrooms; some are private and others are "jack and jill" bathrooms between two rooms. Bathrooms appeared to be clean and had grab bars, however floors needed to be swept and mopped. The shower rooms had non-skid mats. Water temperature measured in four (4) restrooms ranged between 109.2 degrees Fahrenheit and 124 degrees Fahrenheit. Upon observation the Administrator adjusted the hot water temperature in the bathroom between bedroom 13 and 14 that measured 124 F and new water temperature measured at 113.6 degrees Fahrenheit. OUTDOOR: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water were observed. Interviews : The LPA conducted four (4) resident and two (2) staff interviews. No concerns were voiced. Medication Audit: The LPA conducted Medications audit for three (3) residents. The medications are locked in medication carts. Medications are labeled and checked for expiration dates. Medications were observed to not be properly documented on the centrally stored medications and destruction record (CSMDR) as the facility receives a pre-filled CSMDR from the pharmacy however start dates, expiration dates and number of refills for many medications were either not documented or documented incorrectly by the pharmacy. LPA and Med Tech discussed best practices of reviewing and correcting the CSMDR. During Resident 1's (R1's) audit the LPA observed one morning medication was not given on 10/09/25. Additionally, during R2's audit the LPA observed seven (7) morning medications were not given on 10/9/25. Upon observation staff stated that the MT (MT1) on 10/09/25 did not realize both residents had already left for Day Program and did not give them their morning medication. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to the Administrator.