Routine inspection·August 5, 2025

At 09:45 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted a required annual visit to the above noted facility. The LPA met with staff and explained the reason for the visit. Administrator Cleofe Barretto arrived shortly thereafter and was explained the reason for the visit. At 10:00 a.m. the LPA conducted a tour of the physical plant with staff 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 single-story residence that consists of two (2) private bedrooms and two (2) shared bedrooms. Bedroom #1 and #4 have direct access outside. The LPA observed one (1) fire extinguisher which was fully charged and last purchased on 05/16/2024, during today's visit a new fire extinguisher was purchased. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the entrance area. 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. Snacks and beverages are always available for the residents. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding. Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. At 1:50 p.m. water temperature in resident’s common restroom was measured at 109.6 degrees Fahrenheit. Report will continue on LIC809-C, 2nd page. 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. There were no obstructions and/or tripping hazards throughout the facility. The garage: The LPA observed the garage where additional supplies and the emergency water is stored. Cleaning supplies and disinfectants are kept in the garage. Surrounding Grounds (Outdoors) : The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. Record Review: At 10:45 a.m. a review of facility files was initiated. The LPA reviewed five (5) out of five (5) resident files. The following was observed: Resident 1 (R1)'s negative TB test was dated over a year prior to admission, Resident 2 (R2) did not have a signed Appraisal/ Needs and services Plan, and two out five residents (R2, R3) did not have consent for Emergency Medical Treatment forms (LIC627C) on file. Otherwise, all other documents were complete and current. The LPA reviewed five (5) out of eight (8) staff files, all records were complete and current. The LPA observed documentation of Infection Control Plan and Emergency and Disaster Plan and last disaster drill conducted on 07/18/25. The LPA obtained a resident and staff roster. Medication Audit: Medications: At 1:00 p.m. a medications review was initiated for two out of five residents and the following was observed. The medications were stored locked cabinets in the hallway closet and inaccessible to the residents. Medications were properly documented on the Centrally Stored Medication and Destruction Record (CSMDR). During R1's audit, the LPA observed one Sertaline HCL 25 mg pill missing based on the start date and quantity on the CSMDR and bubble pack. During R2's audit the LPA observed that there were still 7 Imodium pills left, however based on the start date, quantity and Medication Administration Record R2 should have finished their Imodium medication by 8/5/25. The LPA observed R2 without a PRN authorization form on file, upon observation the Administrator stated that all three resident that take PRN medications do not have a PRN authorization form. I nterviews: The LPA conducted one (1) resident interview, attempted to conduct a second resident interview and conducted two staff interviews. No immediate concerns were voiced. 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.