Overview: Facility is a two-story home located in a residential neighborhood. Facility is licensed to serve up to 6 adult residents, up to 6 may be non-ambulatory. Facility is fire cleared for 1 bedridden in room #2 of the facility sketch. Facility does manage residents’ cash resources. Facility does not have delayed egress, and/or locked interior/exterior.

Initial Observation: Upon arrival at approximately 1345 hours there were 5 residents in care with 3 staff on duty. LPA observed the fire door to be propped open with an object. Per interview with S1, they keep it open during the day for residents. LPA instructed S1 to keep the fire door close at all times.

Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas.

LPA inspected resident 4 of 4 bedrooms and 2 of 2 bathrooms. All bedrooms are single occupancy. Room temperature was maintained at 73 degrees F. The hot water temperature was measured at 114 degrees Fahrenheit. Fire extinguishers were observed by the kitchen and were serviced on 2/11/26. Smoke and carbon monoxide detectors were observed throughout.

In the kitchen, the facility maintained at least a seven-day supply of non-perishable foods and a two-day supply of perishable foods. Medications, sharps, cleaning supplies, and other dangerous items were observed to be locked and not accessible to residents in care.

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• 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.

Outdoor area was inspected. LPA observed outdoor furniture with umbrella for residents’ use. Ramps, fence, and exit gate were observed to be in good repair at this time. Walkways and ramps were observed to be unobstructed. For the shut off valves, initially, 2 of the staff on duty were unable to locate the gas shut off valves until they called the administrator.

Record Reviews: Review of 3 of 6 resident files was conducted, including but not limited to, review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Advisory provided to administrator to ensure they obtain all their residents’ IPP reports.

Medication reviews were conducted for 2 residents.

Cash (P&I) records were reviewed for 3 residents. Advisory provided to ensure the ledger is updated and available for review.

Review of 4 staff files included but not limited to background clearance, first aid/CPR certification, and training.

Emergency Procedures Plan and Infection Control Plan were reviewed. Facility conducts monthly disaster/fire drills. Reminders were provided to review their plans at least annually.

Documents Requested: LPA requested a copy of updated Liability Insurance Certificate, LIC500, and LIC308 to be emailed to arvin.villanueva@dss.ca.gov.

Per the California Code of Regulations, Title 22, Division 6, Chapter1 & 6, no deficiencies were cited. Advisories were provided.

Exit interview was conducted with administrator over the phone and authorized S1 to sign this report. A copy of the report was provided upon exit.

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