Routine inspection·September 17, 2025

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit. LPA initially met with facility staff. Administrator was contacted via telephone and arrived at the facility at 10:20AM. Entrance interview conducted. Beginning at 11:08AM, the LPA along with the Administrator toured the facility inside and outside to ensure resident health and safety and the facility is in compliance with Title 22 regulation. The smoke alarms and carbon monoxide detectors were tested and functioned properly. The fire extinguishers were purchased on 8/3/2024 and appeared fully charged. BEDROOMS: The facility has seven (7) bedrooms total, one (1) of which is designated for staff use and six (6) are private resident rooms. All resident bedrooms were observed to contain a bed, chair, bedside table, dresser, and lighting. All resident rooms had appropriate bedding. There is an ample supply of linens and towels stored in the cabinets in the hallway. Bedrooms containing exit doors had functional auditory alarms. All residents have a wearable pendant to utilize when staff assistance is needed. RESTROOMS: The facility has three (3) full bathrooms for resident and staff use and one half bath located at the entry. All restrooms contained grab bars and slip-resistant surfaces. Hot water was measured at 109.9 degrees Fahrenheit, which is within the required range. COMMON AREAS: Paint, windows, blinds, and floors are in good repair. The common living and dining areas are clean and properly furnished. A working telephone is present. There is one (1) fireplace in the residence, which was properly screened at the time of the visit. Chemicals are stored in a locked cabinet in the laundry room and in the locked garage. Report Continued on LIC 809-C OUTDOOR SPACE: The facility does have a small birdbath in the backyard; currently no residents are identified as at risk with this water feature. Building and grounds are free from hazard. Patio area observed outdoor shaded seating area for resident use. The one (1) outdoor exit gate was observed to be self-closing and self-latching. KITCHEN: The kitchen contained a sufficient supply of dishes, glasses and utensils. The facility has a sufficient supply of non-perishable food, perishable food and an emergency supply of water is present. Knives are stored in a locked cabinet. Cleaning supplies were observed locked in a cabinet under the sink. The refrigerator/freezer was at the appropriate temperature (40*F and 0*F). RECORD REVIEW: Beginning at 10:09AM (resident files) and 11:33AM (staff files), the LPA began file review. Staff and resident records 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, and personal rights. All four (4) staff files and four (4) resident files observed were in compliance with regulation. All trainings were observed to be complete. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill documented on 06/30/2025. Emergency disaster plan was observed to be complete and updated annually, as required. MEDICATION REVIEW: Medications for two (2) residents were reviewed. Medications were observed stored in a locked cabinet. Medications were prepared for a 7-day period and not in their original containers. Centrally Stored Medication and Destruction Record (CSMDR) was missing start dates for residents' current medications. Start dates observed on individual bubble packs did not match the medication counts. LPA was unable to tell whether medications are being administered as prescribed due to the inaccurate start dates and medications not stored properly. Medication Administration Record (MAR) was observed to be initialed daily for the month of September. A complete medication audit was unable to be completed at this time due to the improper storage and documentation. INTERVIEWS: LPA interviewed two (2) residents and two (2) staff. No concerns noted. Report Continued on LIC 809-C DOCUMENTS REVIEWED/OBTAINED: During today's visit, the LPA reviewed a copy of the facility's register of facility clients, received a copy of the liability insurance and the facility's LIC 500. Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted and copy of the report and appeal rights were provided.