At 9:35 AM, the LPA initiated a walk-through of the facility along with the ED.

LPA inspected six (6) random resident rooms on the third floor, and found them clean, well-lit, and equipped with the required furniture. Emergency pull cords were observed to be functioning in the resident rooms with an average response time of 5 minutes. LPA inspected the private bathrooms in these random rooms. The bathrooms contained soap, grab bars, towels, a trash can, and non-slip flooring. The hot water temperature at the sink faucets measured between 116.5°F and 119.8°F.

LPA inspected the dining room and found it clean, with all the furniture in good repair. Residents were observed eating snacks in the dining room. Cleaning supplies, chemicals, and sharp objects were observed inaccessible to the residents.

LPA inspected activity area and other commons areas and observed some residents participating in the activity and some watching TV. All common areas were free from obstructions and hallways were well-lit.

LPA toured the patio area and found passageways in good condition, free of obstructions, and without any blocking or tripping hazards. These areas had patio tables, chairs, and umbrellas for residents’ use. Delayed egress was observed on emergency exits and patio doors were locked. No accessible bodies of water or hazards were observed.

Continued on 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.

LPA inspected the main kitchen on the first floor and found it clean. The refrigerator, freezer, and pantry were checked, and there was a sufficient supply of fresh perishable food for two (2) days and nonperishable staples for seven (7) days. No expired food items were found. Open food items were wrapped and dated.

LPA inspected the fire extinguishers mounted in the kitchen and found they were fully charged with a last service tag of 02/27/2025. The ED tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional. LPA reviewed the Fire Prevention routine inspection report, conducted on February 06, 2025, by the Department of Fire and Environmental Protection division, City of Mountain View.

LPA inspected the medication room on the second floor. Medications were organized in separate bins for each resident. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records (CSMR) were reviewed and found to be complete. LPA observed and inspected narcotics medications inside a locked centrally stored medication cart located in the dining room.

LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 03/20/2025.

LPA reviewed five (5) random resident files and five (5) random staff personnel records. The LPA observed that 5 of 5 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan. LPA observed that 5 of 5 staff members had First Aid/CPR training, LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 5 of 5 staff members are associated with the facility.

The following updated forms are requested to be submitted to CCLD by 05/19/2025:

1) LIC 500: Personnel Report 2) LIC 308: Designation of Facility Responsibility

3) Certificate of Liability Insurance 4) Administrator Certificate(s)

No deficiencies were cited during today's visit.

An exit interview was conducted with the Executive Director. A copy of this report was left with the Executive Director, Andrew Pence, whose signature on this form confirms receipt of the report.