LPAsAdmi, care staff Mataitoga and Administrator Kaloulasulasu conducted a tour of the physical plant to evaluate the facility's compliance with health and safety requirements. Upon entering the facility, LPAs observed two fire doors leading to resident bedrooms being propped open. During an interview, Staff 1 (S1) stated that the doors are "always open." LPA Lee advised the Administrator Kaloulasulasu and care staff Mataitoga that the fire doors must remain closed at all times and may not be routinely propped open. Areas inspected included, but were not limited to, the kitchen, resident bedrooms, resident bathrooms, living room, dining room, and outdoor areas. LPAs observed that the facility was not free of odors. Hallway No. 1, leading to the residents’ bedrooms, had a noticeable odor of incontinence. Upon entering Resident Bedroom #3, the odor of incontinence was stronger. LPAs also observed Care Staff Mataitoga mopping the floor in Resident Bedroom #3 during the inspection. The facility was observed to be unclean and unsanitary. Specifically, the loveseat and recliner in the dining area were heavily stained and soiled. In addition, the facility was observed to not be maintained in good repair. LPAs observed that the pantry door did not open easily due to the absence of a floor guide/base slider, making the door difficult to operate.

CONTINUED LIC 809-C

• 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.

LPAs observed that toxic substances were stored in a locked kitchen cabinet and were inaccessible to residents. Sharp knives were also secured in a locked cabinet. Medications were stored in a locked area and were inaccessible to residents. The hot water temperature measured 122.5 degrees Fahrenheit at the resident bathroom sink, exceeding the required regulatory range of 105 to 120 degrees Fahrenheit. Bathroom grab bars were secure and in good repair, and nonskid mats were present in the shower. LPAs observed that the facility maintained at least a seven-day supply of nonperishable food and a two-day supply of perishable food. Smoke detectors and fire extinguishers were in compliance with fire safety requirements. The fire extinguisher was last serviced on 11/17/2025, and the most recent fire drill was conducted on 05/28/2026. The first aid kit was complete.

LPAs reviewed and audited medications for four of the six residents by comparing medications on hand with the Medication Administration Records (MARs) and conducting medication counts. During the audit, LPAs determined that the medication count for one of the four residents did not correspond with the resident's medication start date. LPAs reviewed all six resident files and found them to be complete. LPAs also reviewed two staff files. One staff First Aid/CPR certification had expired on 05/31/2026.

The following documents will be emailed to LPA Lee at pang.lee@dss.ca.gov by 07/015/2026 end of day 5:00 PM.