Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents; up to 6 may be non-ambulatory. Facility does not have clearance for bedridden, delayed egress, and secured/locked perimeter. Facility has an approved hospice waiver for 3 residents.

Upon arrival: LPA observed the room temperature to be at 77 degrees Fahrenheit. Four (4) residents were present with 1 staff on duty (AD). Residents were in their bedrooms during this visit.

Physical Inspection: Areas that were inspected include, but not limited to, the resident bedrooms, bathrooms, kitchen area, dining room, other common areas and outdoor areas.

LPA and staff inspected 5 of 5 resident bedrooms and 2 resident bathrooms. Hot water temperature was measured in one of the bathrooms, and it was at 114 degrees Fahrenheit. Private bedroom was observed to be locked. The medication closet was observed to be locked. LPA advised AD to clean the air vent cover, which he completed during this visit.

In the kitchen area, LPA observed at least 7-day nonperishable and 2-day perishable food supplies. Knives/sharps and cleaning solutions were locked. One fire extinguisher was observed by the dining area. Per AD, he purchased it this year. Advisory was provided to attach the receipt to the fire extinguisher. Smoke and carbon monoxide detectors were observed throughout. In the living area, LPA observed the fireplace to be screened.

The outdoor area was inspected, and the fences and gate were observed to be in good repair. No bodies of water were observed. The LPA noted a shaded area with appropriate outdoor furniture available for client use. An advisory was provided, reminding the facility to ensure all staff are familiar with the location and operation of utility shut-off valves in case of emergency.

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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.

Review of 4 of 5 resident file(s) was conducted, including but not limited to, review of Admission Agreement, Physician Reports, and Ambulatory Status. For resident-1 (R1), facility was advised to obtain an updated medical assessment (LIC602A) from their physician due to a change of condition.

Medication review was conducted for 2 of the residents. Facility do not maintain a medication administration records (MAR). Facility was advised to obtain discontinued orders from resident’s physician and to destruct medications that were discontinued. Advisory provided to obtain a signed PRN Authorization document detailing the residents’ ability to communicate their need for PRN medications. LPA provided a sample form. Advisory provided to revise their PRN log records. LPA provided a sample form.

Review of 3 staff files included but not limited to background clearance, first aid/CPR certification, and training. Facility was advised to obtain staff training records from hospice.

LPA reviewed facility’s Disaster Drills. Last drill was conducted in June 2026. LPA advised facility to ensure they maintain quarterly records of their disaster drills. Advisory was provided to administrator to ensure they review their emergency disaster procedure plan at least annually and document each review.

The facility currently has a Mitigation Plan. LPA advised the facility to submit an Infection Control Plan by October 1, 2026 for Department review and approval.

Interviews: 1 staff member was interviewed.

Documents Requested: LPA requested a copy of updated Liability Insurance, Personnel Records (LIC500), and Designation of Facility Responsibility (LIC308) to be emailed to LPA.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6 and Health and Safety Code, no deficiencies were cited. Advisories were provided.

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

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