Firstly, LPA Jamaly inspected the physical plant including but not limited to the common area, kitchen, dining area, 6 resident's bedrooms, resident bathrooms, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

LPAs inspected the kitchen and observed a sufficient supply of at least a seven-day supply of nonperishable food and a two-day supply of perishable food. Sharp knives were secured in a locked kitchen cabinet and inaccessible to residents. LPA checked two refrigerators and freezers; one located in kitchen and in one of the hallways. LPA inspected 6 residents’ bedrooms and observed bedrooms to be properly furnished with appropriate bedding and lighting.

Resident's bathrooms were observed to be cleaned, grab bars and non-slip mats were observed to be secure and in good condition. The hot water temperature measured 114.4 at one of the resident bathroom sinks, which is within the required range of 105°F to 120°F. Facility temperature was checked at living room and observed to be 73 degree F. There are no bodies of water present.
Video Surveillance cameras were installed at front entrance, living room and in the back hallway. LPA observed signed acknowledge forms for video surveillance cameras in resident’s file.

• 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.

LPA Jamaly observed the facility to be free of odor, clean and in good repair. LPA observed that the facility maintained a public telephone in the living room and that all required licensing posters were properly displayed. Cleaning supplies and other toxic substances were observed in a cabinet in laundry room locked and inaccessible to residents.

Medications were observed to be stored in a locked cabinet in the kitchen and inaccessible to residents. LPA reviewed Centrally Stored Medication and Destruction Record and observed to be complete. The first aid kit was inspected and contained all required supplies.

LPA requested resident and staff records for review. LPA reviewed 3 out 6 resident's files. LPA reviewed R1’s LIC 602A and observed that TB test information to be blank. per administrator, R1 physician probably has forgotten to complete the required TB test information and signed it. Deficiency cited on LIC 809D.
Two (2) staff files were reviewed and found to be complete. A review of personnel records confirmed that all staff members and other individuals required to undergo caregiver background checks had received criminal record clearances and were properly associated with the facility.

The following documents were requested and will be emailed to the LPA by 8/26/2026 no later than 5 pm.

1. LIC 308 – Designation of Administrative Responsibility

2. Copy of the Administrator Certificate

3. LIC 610 – Emergency Disaster Plan

4. Proof of Current Liability Insurance

5. LIC 500 – Personnel Report

6. LIC 309 – Administrative Organization

Based on today's inspection, the facility was found to be out of compliance with applicable Title 22 regulations. The deficiency is documented on the attached LIC 809-D Deficiency Report. An exit interview was conducted with Mohamed and copies of the LIC 809 Report, LIC 809-D Deficiency Report, and Appeal Rights were provided to the facility.