Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 ambulatory/non-ambulatory residents. Facility does not have clearance for bedridden, delayed egress, and/or locked interior/exterior. Facility does not manage resident cash resources. Facility does not have hospice waiver at this time.

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

LPA inspected 3 resident bedrooms and 2 bathrooms. Bathrooms are equipped with non-skid flooring and grab bars. Advisory was provided to secure the grab bars with more screws as they were observed to be slightly loose. Faucet, toilet and shower are in working condition. Hot water temperature was 110 degrees Fahrenheit in one of the bathrooms. Room temperature was maintained at 72 degrees Fahrenheit throughout this visit.

In the kitchen, LPA observed at least 7-day nonperishable and 2-day perishable food items. Knives/sharps and cleaning chemicals were locked under the sink. Advisory was provided to obtain thermometers for the kitchen refrigerator and freezer. Advisory was provided to ensure variety of fresh fruits and vegetables were available to residents. Fire extinguisher was observed in the kitchen area and last serviced on 6/20/2025.

The converted garage is labeled “staff” and this is where they store medications and facility records. Additional refrigerator and freezer were in this staff room.

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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.

Record Reviews: Review of 3 of 5 resident files was conducted, including but not limited to, review of Admission Agreement, Physician Reports, and Ambulatory Status. PRN Authorization letters were on file. Advisory provided to ensure they update this form when needed. Needs and Services Plan for 1 of 3 residents was not completed; 2 of 3 residents needs their Needs and Services Plan updated annually. At least 2 residents were assessed to be at risk if they have access to personal/hygiene items. Advisory was provided to facility to ensure they appropriately store these items so that those residents who are at risk do not have direct access. Advisory was provided to facility that there is a new LIC602A form that they can utilize to ensure they are in compliance with the new dementia regulations.

Medication review was conducted for 2 residents, including review of resident’s medication, PRN authorization letter, prescription records, Centrally Stored Medication Records, and Medication Administration Records. Advisory was provided to facility to ensure they have updated prescription records.

Review of 3 staff files included but not limited to background clearance, first aid/CPR certification, and training. Administrator certificate expires on July 2027. Advisory was provided to ensure all staff, including those who are “back up” or “reliever” from time to time have their current first aid/CPR certification on file.

LPA reviewed Emergency Disaster Plan, and they are reviewed at least annually. Fire/Emergency Drill was last conducted 5/17/26. Fire alarm was activated and LPA observed the magnetic fire door closed automatically when the alarm was activated.

Infection Control Plan was reviewed, and advisory was provided to facility to review their plan at least annually. Advisory was provided to facility to review their dementia care plan to ensure it is in compliance with the new dementia regulations.

Documents Requested: LPA requested a copy of updated Liability Insurance, LIC500, and LIC308.

Per the California Code of Regulations, Title 22, Division 6, deficiencies were cited.

Exit interview was conducted with AD. A copy of the report was provided upon exit.

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