Beginning at 11:34AM, the LPAs, along with Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

BEDROOMS/RESTROOMS: The LPAs observed a random selection of 10 (ten) resident rooms, all of which contain private restrooms. All bedrooms were furnished appropriately with clean linens, furnishings and sufficient lighting. Smoke detectors and separate carbon monoxide detectors were tested in various resident rooms and all functioned properly at the time of the visit. Restrooms were clean, sanitary and in operating condition with grab bars and non-slip surfaces. Water temperature was tested in various resident restrooms and temperatures ranged from 113.5 to 115.3 degrees Fahrenheit.

COMMON SPACES: The facility contains multiple common areas throughout, including but not limited to: 3 (three) dining/activity areas, common entry area, and a day room. Walls and flooring were checked for cleanliness and good condition. Department required postings were found in the front lobby near the restrooms. Fire extinguishers were charged and serviced 09/19/2024.

EXTERIOR: The facility has several enclosed courtyards with appropriate outdoor seating for resident use. The swimming pool on the premises was observed to be locked.

FOOD SERVICE: LPAs observed the facility's commercial kitchen, which was locked and inaccessible to residents in care. Kitchen appeared to be clean and appliances operable. Facility has sufficient supply of

Report Continued on LIC 809-C

FILES: The LPAs reviewed a selection of 5 (five) staff files for documents including, but not limited to: health screening, TB test results, background clearance, and training records. All staff records reviewed were observed to be complete and in compliance with regulation at this time. The LPAs reviewed 5 (five) resident files for but not limited to: physician's report, needs and service appraisals, personal rights. All 5 (five) resident files reviewed contained all required documents.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: LPAs reviewed both the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facility conducts emergency disaster drills on each shift quarterly, with the last disaster drill documented on 02/19/2025. Fire system 5-year inspection was completed on 05/16/2024 and the annual inspection was completed on 09/18/2024. Both inspections were conducted by Absolute Fire Protection and all systems passed inspection.

MEDICATION REVIEW: Began at 02:41PM, LPAs, Regional Director of Health Services, along with facility nurse, reviewed medications for 3 (three) residents. 1 (one) resident (Resident #1 - R1) was prescribed Vitamin B complex. The medication was filled on 02/27/2025, but did not have a start date indicated. 5 pills remain in the bubble pack. Administrator and LPA attempted to count the days back, however it appears there is at least 1 (one) pill remaining in the pack that should have been administered. R1's acetaminophen is prescribed three times a day and originally contained 27 pills. The start date is listed as 03/04/2025 and 6 (six) pills are remaining as of the medication review. While it is possible the house supply of acetaminophen was utilized, there is no documentation reflecting this.

INTERVIEWS: Throughout the visit, LPAs interviewed 3 (three) staff and 5 (five) residents. No concerns were noted.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties.

Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided