Routine inspection·September 29, 2025

Licensing Program Analyst (LPA) Valeria Conway arrived unannounced to conduct a one year required annual at 9:15 A.M. Upon arrival, the LPA was greeted at the door by caregiver, Marietta Acosta and contacted the administration via telephone. At 9:39 AM the Administrator, Sara Jackson arrived at the facility and the reason for the visit was explained. Entrance interview conducted. At 9:35 A.M., the LPA along with the 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 following observed: KITCHEN : Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food at the time of the visit. All knives were observed to be locked in a kitchen drawer. At 9:40 A.M. hot water measured 116.8 degrees Fahrenheit. LPA observed a fire extinguisher fully charged and recently purchased on 07/07/2025. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) bedrooms in total. Room between kitchen and garage is designated as a staff room. RESTROOMS: The LPA observed three (3) restrooms in the facility. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. During the physical plant tour, LPA observed that the sink located in the hallway bathroom, situated between bedroom #2 and bedroom #3, was not draining properly (TA issued). Hot water temperature was measured in all three (3) restrooms and was within the required range of 105 - 120 degrees Fahrenheit. Continued on LIC 809-C Continued from LIC 809 COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. A fireplace was noted and was observed to be adequately screened and inaccessible to residents in care. The LPA observed the required postings in the common area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 76 degrees Fahrenheit. Facility has a fire door to contain a fire from one side of the house to the other side. At the time and during the visit fire door was closed. At 10:25 A.M. hardwire smoke alarms were tested and found to be functional at the time of the visit. However, a separate carbon monoxide detector did not contain batteries. The administrator inserted new batteries, but the detector continued to beep. Subsequently, the administrator purchased and installed a new carbon monoxide detector. LPA tested the newly installed detector and confirmed it was functional. OUTDOOR SPACE: The backyard area contains a shaded area with a table and chairs for residents’ use. There was a shaded area with sufficient room for activities. Exit gates were observed to be self-closing and self-latching. Passageways were observed to be clear and free of hazards. No bodies of water noted at the time of visit. GARAGE: A locked garage is accessible from the interior and exterior of the building. Inside the garage LPA observed an extra fridge, emergency water, emergency food and extra medical supplies.Washer, dryer, cleaning supplies and chemicals are safely stored and inaccessible to residents. Continued on LIC 809-C Continued from LIC 809-C RECORDS: Records review began at 11:06 A.M. LPA reviewed four (4) residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Also, LPA reviewed five (5) personnel records including administrator. All files were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. LPA observed a Personnel Record Form (LIC 500) posted at the main entrance with a revision date of 09/06/2024. LPA asked the administrator if the posted version was current and contained accurate information, and the administrator confirmed that it did. LPA then compared the LIC 500 with the Guardian background check system and absorbed that Staff# 1 (S1) is listed on the LIC 500 as a live-in caregiver, however, S1 is not associated with this facility in the Guardian background check system. All files were in order. Last emergency drill (Active Shooter) was conducted on 07/02/2025. MEDICATIONS: Medications review begin at 12:45 P.M., medications are centrally stored and locked in a cabinet under kitchen counter facing the dining room area; medications are labeled and checked for expiration dates. Medications are properly documented on the Centrally Store Medication log provided by the pharmacy at the time of the visit. A first aid kit was observed in the hallway cabinet. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D) An immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49(f). Exit interview conducted. Citations issued. A Copy of report and appeal rights provided.