Routine inspection·September 12, 2025

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:50AM. When the LPA arrived, there were 2 (two) staff and 2 (two) residents present. Facility Designee Amelia (Mae) Davis arrived as facility staff opened the door and greeted the LPA. Beginning at 10:03AM, LPA, along with Facility Designee, conducted a tour of the facility. The following was observed: The facility is a single-story residence that consists of four (4) resident bedrooms and two (2) bathrooms. There is one (1) additional bedroom for staff use that is not identified on the approved fire clearance nor on the facility sketch. It appears a portion of the garage was converted into a staff room, however, Facility Designee could not confirm if permits or approval were obtained for this construction. The fire extinguisher appeared to be fully charged, but was last serviced on 09/06/2024. The hardwired smoke and carbon monoxide detectors were tested at 01:12PM and functioned properly. LPA observed required postings near the entry. Bedrooms: The resident bedrooms were properly furnished with adequate lighting, and clean bedding. Both Resident #1 (R1) and Resident #2 (R2) had half bedrails on their beds, however there were no physician's orders indicating use of postural supports. Bathrooms: The LPA observed one private resident bathroom, one bathroom used by staff, and one shared resident restroom. All bathrooms were clean, properly supplied and had functional fixtures. The LPA observed grab bars and slip-resistant surfaces. Residents have sufficient amounts of supplies for personal hygiene. Facility Designee was advised to secure all personal grooming and hygiene products present in the Report continued on LIC809-C shared resident restroom. The hot water was measured at 117.1 degrees Fahrenheit in the shared resident restroom, which is within the required limit of 105-120 degrees Fahrenheit. Laundry Room: The laundry room cabinets were observed to be locked and contain laundry detergent and other chemicals. Kitchen : The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Sharp objects are stored in a locked drawer to the right of the stove and cleaning supplies are stored in a locked cabinet under the sink. Upon arrival, LPA noted the drawer to be unlocked. LPA advised to keep the drawer locked at all times if any residents are at risk with access to any items stored inside. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature throughout the visit. Surrounding Grounds (Outdoors) : There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. Exit gate was observed to be self-closing and self-latching. Garage: The garage is where additional non-perishable emergency food items are held. Cleaning supplies and disinfectants are kept in the garage. The garage is locked and inaccessible to the residents in care. Facility designee indicated the facility does not have emergency water. File review: Began at 10:20AM. LPA reviewed both residents' files. Resident #2 (R2) was admitted to hospice care on 04/01/2025, however no notification was sent to CCLD as required. LPA reviewed personnel files for 4 (four) staff, including Administrator. The Administrator has not been present at any CCLD visits observed in the facility's history, since the pre-licensing visit in 2022. LPA obtained a copy of the facility's LIC 500, which indicates Administrator is present Monday - Friday 09:00AM to 01:00PM, however was again unavailable during today's visit. Administrator did not have a full and complete file for review at the facility, nor was Administrator able to bring a copy to the facility during today's visit. Administrator is missing a health screening, results from a tuberculosis test, first aid/CPR training, and personnel report. Staff #1 (S1) has been working at the facility for at least 2 months and does have a fingerprint background clearance, however was not associated to this facility. S1 also does not have a health screening or results of a tuberculosis test Report Continued on LIC 809-C on file at this location. None of the 4 (four) staff files reviewed contained proof of the required annual medication training. Additionally, both the Administrator and Staff #2 (S2) did not have proof of CPR nor first aid training. S2 works alone during the overnight shift. Emergency Disaster Plan/Infection Control: The LPA reviewed the facility's Infection Control Plan, Disaster Plan and evacuation drills. Emergency Disaster plan has not been updated since 2022 and contains outdated information. Infection control plan appeared to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last evacuation drill documented on 06/08/2025. Interviews: LPA conducted interviews with 2 (two) residents and 2 (two) staff. No immediate concerns were voiced during the visit. Medication audit: Medications were reviewed beginning at 12:30PM. Medications are centrally stored and locked in a cabinet in the common area. LPA observed medications to be prepared for a 2-week time period, with 9 (nine) days remaining in the pre-prepared medication boxes. Centrally Stored Medication and Destruction Records (CSMDR) for both residents were reviewed and compared to medications present. However, start dates were incorrect as well as refill information and prescription numbers were illegible. Medication start dates were written in including dates in the future. It's possible this is due to the medications being prepared well in advance and improperly stored, however start dates could not have been correct based on medication counts. A complete medication audit was unable to be completed at this time due to the improper storage and documentation. LPA also observed that R1 has over the counter medications, including Bayer Aspirin, Vitamin D3, Centrum Women 50+, and Vitamin C, which were not labeled nor were there prescription orders for these medications. No PRN authorization forms were present for either resident. Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D). 2 (two) civil penalties were assessed, each for $500. Exit interview conducted and copy of the report and appeal rights were provided.