Routine inspection·October 10, 2025

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 09:20 AM. LPA met with facility staff who contacted the facility Co-administrator Michelle Racan and the reason for the visit was explained. Licensee Representatives Bernadette Abiera and Janette Villapando were present for the visit, however they left before the visit ended. Administrator Allan Racan arrived at the facility at approximately 10:30 a.m. Entrance interview conducted and reason for the visit was explained to staff and Administrators. The LPA, along with co-administrator Bernadette Abiera toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN : The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secure cabinet located under the kitchen sink to contain cleaning supplies and knives. LPA observed an additional fire extinguisher mounted in the kitchen to be fully charged and serviced on 08/15/2025. COMMON AREAS : This includes the living room, hallway, and dining room. LPA observed all common areas be clean and properly furnished at the time of the visit. The dining room contains a dining table with adequate seating for resident use. LPA observed the dining room to contain two (2) secured cabinets which contained resident medications and facility files. LPA observed the living room wall to contain all required postings. . Continued on LIC 809C, 2nd page. The living room contained adequate seating and activities for resident use. LPA observed the living room to contain an appropriately screened fireplace. The facility’s fire and carbon monoxide alarms were tested and were functional at the time of the visit. BEDROOMS : There are four (4) resident single occupancy bedrooms in the facility; of which one is vacant.. Bedroom number one (1) is designated as the facility’s bedridden approved room. LPA and facility staff toured all four (4) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Four (4) resident beds were observed to contain full bed rails. At 10:17 a.m. the LPA observed bedroom number one being used as a passage way to a storage/closet inside. At approximately 3:00 p.m. the LPA observed bedroom number one being used as a passage way to a storage/closet inside again. BATHROOMS : There are three (3) bathrooms in the facility. Two (2) bathrooms are designated as private resident bathrooms, and one (1) bathroom is designated as a shared resident bathroom. All resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers all were properly secured. The water temperature was measured between 107.2 and 109 degrees Fahrenheit, water temperature was adjusted during the visit.. GARAGE: LPA observed the garage to be locked and inaccessible to clients in care. The garage was observed to contain cleaning supplies, extra care supplies, adequate emergency food and water supplies, an extra refrigerator, and the facility’s washer and dryer. OUTDOOR SPACE: The facility has two (2) emergency exit gates leading to the front yard of the facility. LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed a secured storage shed. No bodies of water were observed. REC ORD REVIEW: Record review began at 10:52 AM. The LPA reviewed documentation of Infection Control, Emergency Disaster Plan and the facility’s last emergency disaster drill was conducted on 07/09/2025. Three (3) resident and Five (5) staff files 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, consent forms, and personal rights. All records were complete and current. Report will continue on LIC809-C, 3rd page. MEDICATION REVIEW: LPA conducted a medication review for two (2) of three (3) residents and the following was observed: All medications were stored properly inaccessible to residents in care. During Resident #1 (R#1's) audit, the LPA observed zinc oxide paste skin protectant, silicone cream, menthol-zinc oxide .44-20 ointment without a prescription. Per Administrator Allan they are used on R1. LPA observed two unopened prescribed antifungal 2% miconazole nitrate cream tubes (with 9/29/25 filled date) and not documented on the Centrally Stored Medication and Destruction Record (CSMDR), and two unopen Calprotect 0.44-20.6% tubes with filled dates of 7/07/25 and 09/07/25. LPA observed the menthol-zinc oxide .44-20 ointment n ot documented on the CSMDR. The LPA observed Amlodipine besylate 10mg with a start date of 10/8, per MAR given at 8am, only 2 missing, based on count and start date, medication was not given as prescribed . During Resident #2 (R#2's) audit, the LPA observed Lamotrigine 25mg with a start date of 10/9/25 and only only 1 missing for morning bubble pack based on count and start date medication was not administere d as prescribed. The LPA did not observed start dates for R2's potassium chloride and zonisamide INTERVIEWS: LPA attempted to interview two (2) residents, however they were unable or unwilling to be interviewed. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided