Routine inspection·August 8, 2025

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 8:57AM. The LPA met with the Licensee Myline Olivas and explained the reason for the visit. Entrance interview conducted. Beginning at 9:12AM, the LPA and Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The facility is a single-story residential home. The following was observed: COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The living room had a screened fireplace that was inoperable. Required postings were observed in the living room. The facility maintained a comfortable temperature throughout the visit. The facility had an office area located between the kitchen and entryway hallway. The office area contained a desk with files and furniture in good condition. KITCHEN: The LPA observed knives stored inaccessible in a locked drawer. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable and non-perishable food, as well as emergency food. The LPA observed non-perishable food cans expired between November 2024 and June 2025. Food in the refrigerator and freezer were observed to be of good quality and properly stored. One (1) fire extinguisher was observed and last serviced on 08/09/2025. Report Continued on LIC 809-C The Licensee stated they have a scheduled date the following Wednesday to service the fire extinguisher. The kitchen also had two (2) dressers and a file cabinet. One (1) dresser was locked and contained resident medications and the second dresser contained general utilities. The file cabinet was not locked and contained files and several prescribed medications and ointments. The Licensee stated the medications were old and no longer in use. The LPA addressed the accessibility of the file cabinet to which the Licensee said the handle has a push mechanism to open the drawer. The LPA explained the latch was not a sufficient security measure, and the cabinet was accessible to residents. GARAGE: Attached to the kitchen was the garage. The garage remained inaccessible to residents and contained general storage, laundry machines, and additional food. An extra supply of emergency food and water was stored in the garage. The LPA observed non-perishable food cans expired between March 2025 and May 2025. The Licensee stated they would review the food supply and discard expired food. The food in the extra refrigerator and freezer were of good quality. Laundry machines were observed to be operational. BEDROOMS/RESTROOMS: There were five (5) total bedrooms: One (1) staff room that was not locked and contained staff personal belongings, two (2) private resident bedrooms, and two (2) shared resident bedrooms. Bedrooms #2, #4, and #5 had direct exits to the outside, with Bedroom #5 approved for one (1) bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in the hallway cabinet. Upon entering Bedroom #4, the LPA observed one (1) resident’s bed obstructed the direct exit and the placement of the bed did not allow enough space for a walker or wheelchair to pass through and access the exit. The exit doors were unable to fully open. The Licensee and staff pushed the bed away from the exit and was able to access the exit door. There were two (2) total restrooms in the facility: one (1) shared resident and staff restroom located in the hallway, and one (1) private restroom in Bedroom #5. Report Continued on LIC 809-C Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested in the resident restrooms and measured between 113.9 degrees F and 114.3 degrees F which is within the required range. The Licensee stated the residents in Bedroom #4 utilized the private restroom located in Bedroom #5. The LPA explained to the Licensee that the private restroom can only be used by the residents who resided in Bedroom #5 and the Licensee understood. OUTDOOR AREA: The rear yard had multiple shaded areas with furniture in good condition for resident use. The facility had one (1) emergency side exit with a self-latching mechanism. During this time, the LPA observed items including a bag of recyclable bottles hanging on the exit, a bag of clothes leaning against the exit, a carpet, a tarp, a mop bucket, and a box. The Licensee stated these items needed to be discarded. The LPA stated the exit passageways need to remain unobstructed. RECORDS: Record review began at 9:45AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. Resident #1 (R1) did not have a signed Physician’s Report or a TB test result on file and did not have an Emergency Identification form. R1’s Pre-Admission Appraisal was not signed and R1’s most recent Appraisal was not completed or signed. Resident #2 (R2) did not have a TB test result on file and Resident #3’s (R3) most recent Appraisal was not completed or signed. The Licensee stated that families requested to keep the Appraisals short therefore the Licensee does not fill out the forms completely. The LPA discussed with the Licensee that the Appraisals determine how the facility address the needs and services of residents, and the forms need to be completed in its entirety to monitor the residents’ conditions. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Records were in order. Report Continued on LIC 809-C INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 08/05/2025. Smoke and carbon monoxide detectors were tested at 9:38AM. MEDICATIONS: Medication review began at 11:40AM. Medications were centrally stored and kept inaccessible. Medications were observed for three (3) residents. Medications were labeled and checked for expiration dates and were not properly documented on the centrally stored medications and destruction record (CSMDR). R1 had sixteen (16) prescribed medications, nine (9) of which were PRN (as needed) medications, that were not accurately documented on a CSMDR. R1 did not have a PRN Authorization Letter. R2 did not have a current CSDMR and the Licensee stated R2’s medications were delivered the previous night and staff have not made the updated list because “we are busy.” R2’s most recent CSDMR update was 06/03/2025. Resident #4’s (R4) CSMDR was not accurate or updated. R4’s most recent CSDMR update was 02/07/2025. Staff utilized an app to update resident medications which then converts into an excel sheet. Staff provided the LPA a “master” list of all residents CSDMR. Upon review of the master record, Resident #5 (R5) also did not have a maintained CSDMR with medication information missing. Pursuant to Title 22 CA Code of Regulations and/or Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D). An immediate civil penalty of $500 for a violation of the facility’s fire clearance was issued (Refer to LIC 412M). The Licensee understands that continued violation of the facility’s fire clearance may result in additional civil penalties. An immediate civil penalty in the amount of $250 for a repeat citation was issued (refer to LIC 421FC). The Licensee was informed that failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.