• 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 observed surveillance cameras installed in the common areas of the facility. The Administrator presented the live monitoring screen to the LPA, confirming that one (1) camera of three (3) were functioning properly and that none of them were equipped with audio capability.

KITCHEN: The LPA inspected the kitchen/food service area. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 112.6 degrees Fahrenheit. Cleaning supplies and other chemicals are kept under the sink locked and inaccessible to residents in care.

BEDROOMS: There are six (6) total bedrooms in the facility; all six (6) bedrooms are designated as private, single occupancy, resident rooms. There is no staff room and Administrator stated that staff remain awake at night. All six (6) resident rooms have exits to the exterior. All passageways were observed to be clear of obstructions. All rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. Each bedrooms have its own supply of linens stored in the closet.

RESTROOMS: There are four (4) total restrooms. One is designated as a shared / common resident restroom, two are designated as private resident restrooms, and One (1) is designated as guest / staff restroom. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 112.6 -120 degrees Fahrenheit, all within the required range. LPA advised Administrator of the regulatory standard of 105 -120 degrees Fahrenheit as the water is at the maximum. LPA observed storage space closets in the hallway containing extra clean linens and towels for resident use. Report Continued on LIC 809C PAGE 3...

BACKYARD: The entire property is fenced. The LPA observed the back yard which had portable outdoor umbrellas for shade along with patio furniture including tables and chairs for resident use. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit. One (1) pathway is used as an emergency exit which was free of obstructions at the time of the visit.

RECORDS: Resident Records were reviewed beginning at 2:17 p.m. Two (2) 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, Home Health records, Hospice records, PRN authorization letters, and current needs and services plan. All records were in order. Personnel Records were reviewed beginning at 2:31 p.m. four (4) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required, 01/01/2026. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard.

MEDICATIONS: Medication review began at approximately 12:01 p.m. Medications are centrally stored and locked in a closet adjacent to the entrance. Medications for two (2) residents were reviewed. Medications are labeled and checked for expiration dates. During the review LPA observed two (2) out of two (2) residents medications to not be documented properly on the centrally stored medications and destruction record which poses/posed a potential health, safety or personal rights risk to persons in care. At the time of the visit the Administrator began to properly document both residents medications along with auditing the medications. Administrator agreed to audit the medications by POC due date. LPA observed the first aid supplies to be complete, including sterile first aid dressings, bandages, tweezer, a thermometer and a current version of a first aid manual. Report Continued on LIC 809C PAGE 4...

DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster, LIC 9020A Resident roster, copy of the Limited Liability insurance, and permits for alterations / addition of a bathroom in bedroom #6.

At the time if the visit the LPA reviewed the facilities contact information on file including phone numbers, email and annual fees. Administrator updated facility phone number and confirmed that all information is accurate.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.