The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE), with an approved fire clearance capacity of Forty-Three (43) residents. The facility is approved for 43 non-ambulatory residents, of which five (5) may be bedridden, with an age range of residents sixty (60) years of age and older. The facility has an approved Hospice Waiver for twenty (20) residents. The physical plant of the facility consists of a semi separated building (2 indoor areas) connected by an outdoor courtyard. The two (2) buildings are separately labeled by the facility as the "Main" building and the "Casa" building. The Main building consists of resident bedrooms, restrooms, shower areas, a Centrally Stored Medication room, nursing station room, two (2) dining room, kitchen, activity room, storage area closets/rooms, and a beauty salon, Staff offices, and a central lobby administrative area upon entry into the facility. The Casa building consists of resident bedrooms, nursing station room, shower area, dining room, Lounge room, restrooms, and storage closets/rooms. The outdoor courtyard between the buildings of the facility contains a locked indoor service area which is the designated laundry room area of the facility. The facility contains an outside area for residents to utilize for outdoor activities/outdoor visitations and an outdoor patio/courtyard area with furniture and shade.

KITCHEN: The facility maintains one (1) main kitchen room/area for both the Main building and the Casa building of the facility. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked drawer inaccessible to residents. Kitchen appliances were in operable condition and looked clean/in good repair. Continued on 809-C

COMMON AREAS: The indoor areas of the facility consist of semi separated building(s) (2 indoor areas) connected by an outdoor courtyard. The two (2) buildings are separately labeled by the facility as the "Main" building and the "Casa" building. The Main building consists of resident bedrooms, restrooms, shower areas, a Centrally Stored Medication room, nursing station room, two (2) dining room, kitchen, activity room, storage area closets/rooms, and a beauty salon, Staff offices, and a central lobby administrative area upon entry into the facility. The Casa building consists of resident bedrooms, nursing station room, shower area, dining room, Lounge room, restrooms, and storage closets/rooms. At the time of the visit, the common areas of the facility were observed to be appropriately furnished, with all furniture in good condition. There are no fireplaces in the facility, therefore no need to be inaccessible to residents. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector(s) were operational at the time of the visit. The facility has multiple fire extinguishers that were fully charged and serviced annually, all being tagged as serviced in 2023. This facility contains multiple dining rooms, a Lounge, Staff offices, a beauty salon/barber, nursing stations, five (5) resident restrooms, three (3) resident shower/bathing rooms, living room area, kitchen area, dining room, laundry room, twenty-five (25) resident bedrooms (both individual and shared), a locked centrally stored medication containment area, extra storage areas for additional perishable food, closets/rooms in the hallways of the facility containing extra linen/bedsheets/pillows, and storage areas for resident personal hygiene equipment constituting the interior areas of the facility. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. Continued on 809-C

OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility is well maintained and consists of cement walkways and grass areas. The facility outdoor courtyard between the Main indoor building and the Casa indoor building is well maintained and is paved with a walkway between the facility. The backyard is conducive for outdoor visitation. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. The exterior of the facility has a closed perimeter which consists of a wall around the entire facility with latched gates. Inside of the perimeter is the outdoor/outside activity area for residents with a patio in the backyard, furniture, shade, and sheds that are locked and contain outdoor maintenance materials for the facility. LPA was shown the inside of all sheds upon request. There is also a second story to the Casa building of the facility that consists of a Staff member break room and a Staff member private kitchen along with Staff offices. This area is locked and inaccessible to residents. The facility has an outdoor activity area that is provided with a shaded area and furnished for outdoor use. There are no bodies of water noted on the facility property. The designated laundry area is a locked room in the back of the facility, and there is another locked storage area where cleaning products are stored, which are kept locked and inaccessible to residents. The laundry room is always locked and accessible through the back door of the Main building of the facility, next to another locked area which has all emergency items locked with electronic combination locks. Staff members are the only individuals allowed to do laundry and the entire room is kept locked at all times. There was emergency food and water in a storage area in the back of the facility and in the extra perishable food storage area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents. Continued on 809-C

BEDROOMS: The facility has twenty-five (25) resident bedrooms, both individual bedrooms for one (1) resident and shared bedrooms for two (2) residents. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The bedrooms have storage areas for clean linens, towels, pillows, etc. Each resident’s bedroom has a single bed or beds, nightstand, and lights/nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assistive device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. All resident bedrooms in the Casa building of the facility contain their own private restroom within the bedroom area. All resident bedrooms contain monitored signal/auditory/call system in place by the facility that alerts Staff when a resident needs assistance.

RESTROOMS: There are five (5) resident restrooms and three (3) resident shower/bathing rooms in the facility. The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms/showers inspected had assistive equipment for residents including grab bars and/or non-skid surfaces. The restrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit. Nightlights are installed in the hallways outside of the resident restrooms. The facility maintains private, personal restrooms for residents in each resident bedroom of the Casa building. The Main building has communal restrooms for residents in the hallways. All resident restrooms consist of a sink and toilet with soap, paper towels, and additional supplies, while the resident shower/bathing areas consist of a shower and/or bathing area with assistive equipment such as grab bars and non-skid surfaces. Continued on 809-C

RECORDS: The facility keeps confidential storage of both resident and Staff member records on-site at the facility. Staff member records were reviewed for, but not limited to Health Screening Report/Tuberculosis (TB) Clearance for facility personnel, Personnel Record (employment application), verification of age over 18 years old, education, and experience, approved Certification for the Administrator, verification of first aid training, Criminal Record Statement, Continued on 809-C

MEDICATIONS: The facility maintains a locked centralized storage area for resident medications in each building. Centrally Stored Medications are in a locked storage containment area within the medication room of the facility, which is located in the Main building of the facility. Centrally stored medications for the Casa building are stored in the Nursing Office/Room which is also locked and inaccessible to residents. In both instances, the medications are stored within a locked cabinet/cart that remains locked within those areas, inaccessible to residents. The medication rooms remain locked at all times, inaccessible/locked to residents. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record, The Medication Administration Record, and the record of Controlled Medications. LPA audited the medications for residents and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

Continued on 809-C

A Type A deficiency was cited for California Code of Regulations (CCR) 87355(e)(2) Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c). The Licensee did not ensure that one (1) Staff member was associated to the facility prior to working in the facility, which poses an immediate safety risk to persons in care. Exit Interview Conducted. Copy of the Report provided to the Facility.