Routine inspection·July 2, 2025

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 8:45AM. The LPA met with staff and explained the reason for the visit. Administrator Arlene Martinez arrived shortly thereafter. Entrance interview conducted. Beginning at 8:55AM, the LPA, along with Caregiver Avelina Giron 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: Facility is a double-story residence, second floor is solely designated for staff. Fire extinguisher was fully charged with purchase date of 04/30/2025. Hardwired smoke and carbon monoxide detectors were tested at 09:17AM and all were functional at the time of the visit. LPA observed exit alarms by all doors which were functional during the visit. KITCHEN: LPA inspected the kitchen at 9:50AM. Knives are locked in a drawer next to the sink and cleaning supplies are stored inaccessible in a locked cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS : There are 4 (four) total resident bedrooms in the facility; 2 (two) are designated as private resident rooms and 2 (two) are designated as shared rooms. Bedrooms #1 and #4 have exits to the exterior and attached bathrooms. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space.. The bedrooms were large enough to allow for easy passage. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. COMMON AREAS : This includes the living room, dining area, and office room. LPA observed common areas to be clean and properly furnished at the time of the visit. Report Continued on LIC 809-C, 2nd page. BATHROOMS : There are 3 (three) total resident bathrooms, of which 2 (two) are inside resident rooms. Restrooms were observed clean with nonskid mats, and grab bars by the showers and toilets. The water temperature was measured in the communal bathroom at 135.5 degrees Fahrenheit and in the bathroom inside room #4 which measured at 130.0 Fahrenheit degrees. LPA observed storage space closets in hallway containing clean linens for resident use. OUTDOOR SPACE/GARAGE: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. LPA observed 2 (two) latched self-closing side gates. LPA toured the garage. The garage has a washer and dryer, locked cleaning supplies, an additional refrigerator and freezer, an emergency water supply and an additional pantry for extra food. RECORD REVIEW: A review of facility files was initiated at 9:50 a.m. Facility records are stored in a locked cabinet in the office room. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 06/20/2025). The LPA obtained Resident Roster, Staff Roster and Insurance liability. The LPA reviewed 5 (five) out of 6 (six) resident files and five (five) out of nine (9) staff files 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. The LPA observed the following: Resident 1 (R1) did not have a current appraisal/ needs and service plan on file and Resident 2's (R2's) physician report (LIC602) did not have pages 3-5 filled out. Staff 1(S1) did not have a health screening and TB test results on file. MEDICATION REVIEW: Medications are locked in a cabinet in the office. Medications for two (2) residents were observed. Medications are labeled and checked for expiration dates. Facility receives a pre-generated Centrally Stored Medications and Destruction Record (CSMR) from the pharmacy where staff only need to document the start date. The following was observed: During Resident 2's (R2's) audit, the LPA observed four medications (Docusate Sodium, Olanzapine, Mirtazapine, and Melatonin) on the CSMR with the start date of 07/1/2025, however, the facility did not have Olanzapine, Mirtazapine or Melatonin for the resident; Additionally, Docusate Sodium was still being given even though observed to be crossed out from the medication list provided by Home Health. Upon observation, the Administrator stated, that Olanzapine had not been delivered yet, Mirtazapine and Melatonin were discontinued and was not aware that Docusate Sodium was also discontinued. Report will continue on LIC809-C, 3rd page. INTERVIEWS: During today's visit, LPA interviewed three (3) residents. Resident interviews revealed that activities are not provided. The LPA did not observe any activities being provided during the visit. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.