Routine inspection·October 15, 2025

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 10:25AM. When the LPA arrived, there were 2 (two) staff and 5 (five) residents present. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Alexander Tecson was unable to be present during today's visit and authorized facility designee Amelia (Mae) Davis to review and sign reports. Entrance interview conducted. Beginning at 10:50AM, the LPA, along with facility designee conducted a tour of the physical plant 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 five (5) resident bedrooms and three (3) bathrooms. The LPA observed 2 (two) fully charged fire extinguishers last serviced on 09/15/2025. Hardwired combination smoke alarms and carbon monoxide detectors were tested and functioned properly during time of visit. LPA observed all required postings throughout the facility. Bedrooms/Bathrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed full bed rails on all 5 (five) residents' beds. Record review revealed 2 (two) residents (Resident #1 - R1 and Resident #2 - R2) are receiving hospice services however, neither R1 nor R2's hospice care plans indicated the need for full bed rails. There are 3 (three) full bathrooms in the facility; 2 (two) are located in the hall and are designated for shared use, 1 (one) is designated for private resident use. Report Continued on LIC 809-C 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. The facility maintained a comfortable temperature throughout the visit. LPA noted that the front door contains a dead bolt that requires the use of a key to unlock/lock on the exterior and interior. The door was observed to be locked with a key. Facility Designee unlocked the dead bolt during the visit. Hall closets are locked and contain resident personal care/grooming items, and one closet contained resident medications. 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. Sharp objects are stored in a locked drawer. Garage/Laundry Room: The garage is locked and used as a storage. The laundry equipment and cleaning supplies are kept in a locked outside laundry room. Attached to the facility garage is a staff room, which was observed to be locked. Surrounding Grounds (Outdoors) : There was a shaded area with proper furniture for outdoor use. The backyard contains a water fountain and a small birdbath. LPA advised facility designee to ensure residents' medical assessments are updated to reflect the regulation changes effective 01/01/2025 which address resident risk with access to smaller water features. File Review: Beginning at 11:10AM, LPA reviewed 4 (four) staff and 5 (five) resident records 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 4 (four) of 4 (four) staff files reviewed were complete and contained all documents. All 5 (five) of 5 (five) residents have full bed rails on their beds, but are either not on hospice or do not have hospice care plans which indicate the need for full bed rails. Medication Audit: Medications were reviewed beginning at 12:30PM. Medications are centrally stored and locked in a cabinet in the hallway. Medications for 2 (two) residents were observed. Medications observed appeared to be administered and documented in compliance with regulation. Emergency Disaster Plan/Infection Control: The LPA reviewed the facility's Infection Control Plan, Disaster Report Continued on LiC 809-C (p.3) Plan and evacuation drills. Both Emergency Disaster plan and Infection control plan appeared to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last evacuation drill documented on 09/29/2025. Interviews: LPA conducted interviews with 1 (one) resident and 2 (two) staff. No immediate concerns were voiced during the visit. Documents Obtained: LPA received a copy of the facility's liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Civil penalty issued in the amount of $500. Exit interview conducted and copy of the report and appeal rights provided.