Routine inspection·February 2, 2026

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:45 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator, Melissa Shubin arrived shortly after and the reason for the visit was explained. Entrance interview. The LPA and Administrator 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 facility is a single-story home located in a residential neighborhood. COMMON AREAS: This includes the living 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 1:52 p.m., hardwire combination of smoke / carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 12/04/2025. The emergency exiting plans/sketch are posted. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 12/22/2025 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. Auditory alarms at the entrances and exits were observed and functional at the time of the visit. INTERVIEWS : Starting at 9:57 a.m. two (2) staff and two (2) resident interviews were conducted. Staff interviews revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit. Report Continued on LIC 809-C PAGE 2 ... (PAGE 2) Report Continued from LIC 809-C... BEDROOMS: There are five (5) total bedrooms in the facility; four (4) bedrooms are designated as private, single occupancy, resident rooms and one (1) is designated as a shared, double occupancy resident room. There is no staff room and Administrator stated that staff remain awake at night. Two (2) out of five (5) 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. RESTROOMS : There are two (2) total restrooms. One (1) is designated as a shared / common resident restroom, One (1) is designated as a private resident restroom. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 106.2 - 106.7 degrees Fahrenheit, all within the required range. LPA observed storage space closets in the hallway containing extra clean linens and towels for resident use. KITCHEN: The LPA inspected the kitchen/food service area. Knives and sharps were observed in a locked cabinet. 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 within the required range. Cleaning supplies and other chemicals are kept under the sink locked and inaccessible to residents in care. LAUNDRY ROOM: LPA observed the locked laundry room adjacent to bedroom #5. Laundry room has a washer, dryer, detergent and is kept locked at all times. 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 one single latching gate. LPA observed a covered, locked, empty jacuzzi at the time of the visit. LPA observed one (1) detached, outdoor garage which contained furniture and is inaccessible to residents. Only one (1) pathway is used as an emergency exit which was free of obstructions at the time of the visit. GARAGE: The facility has two (2) garages. One (1) attached and one (1) detached. The attached garage is accessible from the home adjacent to room #5 and staff rest area. LPA observed a portion of the garage to be used as on office, and the remainder as storage of emergency food and water, personal protection equipment (PPE) , incontinent supplies, and an extra refrigerator/freezer that was checked for proper labels and expiration dates.LPA observed two (2) of two (2) garages. Report Continued on LIC 809-C PAGE 3 ... (PAGE 3) Report Continued from LIC 809-C PAGE 2... RECORDS: Resident Records were reviewed beginning at 10:41 a.m. Four (4) 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, PRN authorization letters, and current needs and services plan. All records were in order. Personnel Records were reviewed beginning at 11:31 a.m. five (5) 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. Two (2) out of five (5) staff training's were missing the specific date and time they were conducted. INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard. MEDICATIONS: Medication review began at approximately 1:19 p.m. Medications are centrally stored and locked in a closet adjacent to bedroom #5. Medications for two (2) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were properly documented on the centrally stored medications and destruction record, stored, locked and inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed. No errors observed during review. LPA observed the first aid supplies to be complete, including sterile first aid dressings, bandages , tweezer , a thermometer and a current version of a first aid manual. DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster and LIC 9020A Resident roster and copy of the Limited Liability insurance. At the time if the visit the LPA reviewed the facilities contact information on file including phone numbers, email and annual fees. Administrator confirmed that all information is accurate. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.