At 8:46 AM, the LPA initiated a walk-through of the facility, accompanied by the DSP.

There are (3) bedrooms and (2) bathroom designated for residents' use. (2) resident bedrooms are private and (1) resident bedroom is shared occupancy. (1) Resident bedroom had a private bathroom. LPA inspected all (3) resident rooms and found them clean, well-lit, and equipped with the required furniture.

At 8:58 AM, LPA inspected the resident’s private bathroom in shared occupancy room and observed Lysol Disinfectant spray bottles, comet bleach under the sink cabinet unlocked and accessible to the residents. LPA observed the bathroom clean, sanitary, and in good working condition. It contained soap, grab bars, a trash can, non-slip mat and flooring. The hot water temperature at the sink faucet was measured at 113.5°F. LPA inspected the common bathroom and observed Clorox bleach, Comet bleach, Lysol cleaning solutions under the sink cabinet unlocked and accessible to the residents. This bathroom contained soap, grab bars, a trash can, shower tub with curtain, and a non-slip shower mat. The hot water temperature at the sink faucet was measured at 114.6°F. The Administrator removed all the Disinfectant, bleach and cleaning solutions from both the bathrooms and placed them in a locked cabinet in the laundry area.

LPA inspected the kitchen and found it clean, with no food preparation or cooking in progress at the time. LPA checked the appliances and observed them in working order. The locked cabinet containing knives and the locked cabinet under the sink with soap and cleaning supplies were also inspected. LPA inspected the refrigerator and pantry cabinets and observed enough supplies of fresh perishable food for (2) days and nonperishable staples for (7) days. No expired food and no stored medications were noticed.

Continued on LIC809-C

LPA inspected the storage space in the hallway and observed it containing clean linens and towels for residents’ use.

LPA inspected the laundry room and observed a washer and dryer. There was a locked storage cabinets containing cleaning detergents and soap solutions.

LPA inspected the garage and observed a refrigerator containing additional food supplies, storage racks for non-perishable food items and paper products. LPA observed a computer station along with the file cabinets.

LPA toured the backyard area. The backyard had a set of patio table, chairs, and a umbrella. There were no bodies of water noted and was found clear of obstructions. The walkways were found clear without any tripping hazards.

The LPA reviewed (3) staff personnel records and (3) resident records. The LPA observed that 3 of 3 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan. LPA observed that 3 of 3 staff members had First Aid/CPR training, LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 3 of 3 staff members are associated with the facility.

LPA observed a locked centrally stored medication cabinet located inside the kitchen. Medications were organized in separate bins for each resident. All medication bottles were properly labeled. Centrally Stored Medication Records (CSMR) were reviewed and found to be complete.

LPA inspected the first aid kit and observed it fully stocked. The administrator counted Resident P&I money in front of the LPA and records indicated the correct amount.

LPA reviewed Emergency Drill Logs and observed Emergency Disaster Drills were conducted every month, with the most recent earthquake drill completed on 10/29/2024.

Continued on LIC809-C

• LIC 500: Personnel Report
• LIC 308: Designation of Facility Responsibility
• Certificate of Liability Insurance
• Surety Bond
• Current Property Lease Agreement
• Administrator Certificate(s)

No deficiencies were cited during today's visit.

An exit interview was conducted. A copy of this report was left with the Administrator, Orlando Ferrer, whose signature on this form confirms receipt of the report.