The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control plan is on file.

· The facility is a single-story home located in a residential neighborhood. The facility consists of four (4) resident bedrooms, an office, a caregiver room, a kitchen, dining room, a living room, and an attached garage that contains the washer and dryer for the facility. The facility contains three (3) bathrooms including checking their water temperature, which all fell within the required range of 105 – 120 degrees Fahrenheit. The carbon monoxide detector is operational in the home. A fully charged fire extinguisher is kept on the premises.

• 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.

· Fire clearance was approved by LA County Fire Department for a capacity of six (6) non-ambulatory residents, and a hospice waiver approved for six (6) residents.

· During record review of the residents’ files, it was determined that five (5) residents are listed as non-ambulatory, however the maximum number of residents that may be non-ambulatory in the facility is four (4), which exceeds its limit. Resident #1 (R1) is listed as non-ambulatory based on their physician's report, however administrator stated they are ambulatory. Administrator explained that she will work towards obtaining an updated physician report for R1.

Staffing:

· Eleven (11) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Five (5) staff files were reviewed for criminal background clearance and training.

Resident Rights/Information:

· Physician orders were reviewed for six (6) resident files.

· Medications were also reviewed for six (6) residents.

Resident Records/Incident Reports:

· Six (6) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Incident Medical and Dental:

· All residents have are assisted with medication management by staff.

Disaster Preparedness:

· Emergency and Disaster Plan (LIC610E) was posted in the facility and LPA obtained a copy.

· The last emergency and disaster drill was conducted on 6/25/2026.

Planned Activities:

· Sufficient Space is provided to accommodate both indoor and outdoor activities.

· Sufficient equipment and supplies are provided to meet the requirements of the activity program.

Residents with Special Health Care Needs

· There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal.

· Documentation was shown that a home health agency provides care for Resident #3’s colostomy care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on the LIC809D page. Exit interview held and a copy of the report along with appeal rights were provided.