The facility is licensed to provide care and supervision to six (6) residents, age 60 and older. The approved capacity includes up to four (4) non-ambulatory residents and one (1) bedridden resident.

Facility Tour & Observations

Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present.

Physical Plant

The facility is located in a residential neighborhood and is a single-story home consisting of five (5) resident bedrooms, three (3) bathrooms (including one private resident bathroom and one staff bathroom), a living room, kitchen, dining area, laundry room, garage, front yard, and backyard. LPA observed all five (5) resident bedrooms, which were equipped with the required furnishings, including a bed, mattress, linens, dresser, chair, and adequate lighting. During the inspection, LPA observed cleaning supplies and toxic substances stored in the kitchen cabinet beneath the sink that were accessible to residents as current lock was broken. A deficiency was cited. The bathrooms were clean and equipped with the required grab bars near the toilets and in the shower areas, as well as non-skid mats. Hot water temperature measured within the required range of 105°F to 120°F. An adequate supply of extra linens and towels was available in a hallway cabinet. Smoke and carbon monoxide detectors were tested and found to be operational. Fire extinguishers were observed throughout the facility and were readily accessible. No bodies of water were present on the premises. The backyard contained shaded seating areas for resident use. All passageways, walkways, and exits were observed to be clear, unobstructed, and free of hazards.

(continued on 809C)

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

Refrigerators/freezers were maintained at proper temperatures (refrigerators maximum of 40 degrees °F and freezer 0-degree °C) with sufficient supply of 2-day perishable and 7 days non-perishable food. Fresh produce, proteins, and dry goods were stocked. Knives and were observed in a locked kitchen drawer.

Health-Related Services & Records

Three (3) resident files were reviewed. All files contained Admission Agreements, Pre-Placement Appraisals, Consents, Rights Acknowledgments, Re- Appraisals and current TB screening documentation. However, Resident 1 (R1)'s file did not contain an exception on file authorizing the use of full bed rails. Additionally, Resident 3 (R3) and Resident 4 (R4) did not have physician's orders authorizing the use of half bed rails. A deficiency will be cited for failure to maintain the required physician's orders in the resident records.

Three (3) residents' medications were reviewed. No concerns were identified during the medication review. Medications were observed to be centrally stored. Medication Administration Records (MARs) were reviewed and found to be current and accurately maintained.

Disaster Preparedness

The last documented fire and earthquake drill was conducted on April 23, 2026, and drill logs were available for review. The LIC 610D Emergency Disaster Plan was posted near the entrance of the home. Emergency disaster supplies were observed to be available. The facility's Infection Control Plan was current and available for review.

Personnel Records & Training

Three (3) staff files were reviewed. All three (3) files contained documentation of criminal record clearances, current CPR/First Aid certifications, required annual training, and current TB screenings.

Insurance

Liability insurance was in compliance with an expiration date of July 22, 2026.

An exit interview was conducted with Victoria Serna,Care Manager. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided