Beginning at 10:34 a.m., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Kitchen: The LPA observed the kitchen/food area at approximately 10:36 a.m. The kitchen appliances appeared to be clean and in operable condition. The facility has a sufficient supply of non-perishable and perishable food; properly stored. Refrigerator and dry food pantry were checked for proper labels and expiration dates. Knives and sharps were observed in a kitchen cabinet locked and inaccessible.

Bedrooms: There are three (3) bedrooms designated for resident use. The LPA observed all resident bedrooms to be properly furnished with a bed, clean linens, furniture chest with drawers, a chair, and sufficient lighting. Staff room was observed on premises locked and inaccessible to residents at the time of the visit.

Report Continued on LIC 809C...

• 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.

Common Areas: The LPA observed the living room and dining room area to be furnished appropriately, and all furniture was observed to be in good condition at the time of the visit. The facility maintained a comfortable temperature. The LPA observed required postings throughout the common space. Activities for residents were observed in the living room. There is a working telephone on premises. The facility has an adequate amount of emergency food and water. The LPA observed an adequate amount of Personal Protection Equipment (PPE).

At 10:51 a.m., the smoke detectors and carbon monoxide detector were tested and were operational at the time of the visit. No obstructions or hazards were observed inside or out.

Garage: The garage was locked and inaccessible to residents at the time of the visit.

Outside / Backyard: There is a shaded area in the backyard with appropriate furniture for resident use. The exterior passageways were clean and clear of any obstructions at the time of the visit. The LPA observed one (1) self-latching gate for emergency use. There is a pool that was observed to be locked and inaccessible at the time of the visit.

Laundry: The laundry room is located in the backyard. There is a washer and a dryer. Staff assist residents with all laundry needs. Detergents were observed in a locked cabinet inaccessible to residents at the time of the visit.

Report Continued on LIC 809C...

Record Review: The LPA reviewed four (4) Resident Records and two (2) Personnel Records including the current Administrator’s file starting at 09:55 a.m.

Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan/IPP. All files were complete.

Personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR certifications, and yearly necessary training. All records were in order.

Administrator’s Certificate is active until 08/31/2027.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2i home.

Emergency Disaster Planning: During today’s visit, the LPA reviewed the facility's emergency disaster plan. The facility's emergency disaster plan was observed to be complete and recently reviewed/updated. Fire extinguisher was observed to be fully charged with a charge date of 07/11/2025. Emergency disaster drills are being conducted at least once per quarter; last emergency disaster drill was a fire drill which was conducted on 12/17/2025.

Medication Review: The LPA conducted a medication review. Medications are centrally stored in a locked cabinet adjacent to the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medication were observed properly documented on the Centrally Stored Medication & Destruction Record (CSMDR) and appear to be given as prescribed at the time of the visit.

No citations issued. Exit interview conducted. Copy of the report was provided.