Starting at 12:27 p.m., the LPA, along with facility staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards. The following was observed:

BEDROOMS: The facility consists of five (5) bedrooms: three (3) are designated for private client use, one (1) is a shared client bedroom, and one (1) is a staff room. The LPA observed client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. Staff stated the staff room remains locked.

RESTROOMS: Client restroom is relatively clean and sanitary and in operating condition. Hot water temperature was measured at 118.4 degrees Fahrenheit. The sinks had sufficient liquid soap, and paper towels.

GARAGE: The garage is attached to the house. Washer and dryer units are located inside the garage. Emergency water and emergency canned food is located inside the garage. Knives are stored in a locked cabinet inside the garage. Cleaning solutions, and chemicals are inaccessible and locked away in the garage. LPA reminded staff to ensure locks are engaged on the cabinets for client safety.

Report 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.

COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguishers to be fully charged and last serviced on 05/20/2026. At 03:30 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. Facility telephone was observed during the time of the visit. Medications are located inside the staff room and first aid kit is located in the living area.

KITCHEN: The LPA observed the kitchen and dining area. Kitchen appliances are in operable condition. The LPA observed the facility food. Staff indicated the garage fridge is staff food only, so this supply was not observed. The kitchen fridge is for storing client food and contained three (3) bags of coleslaw which were expired and spoiled. No fresh fruits were observed. In the garage there was a bowl of potatoes and bowl of onions, but no additional fresh vegetables were observed. The freezer contained food purchased by individual clients, one (1) bag of frozen french fries, hot link sausage, sausage links and one (1) additional probable protein item. The pantry had two (2) cereal boxes containing less than a serving each, a small container of oats, flour, sugar, and various client-purchased foods. Clients interviewed stated they were not offered breakfast this morning and the two (2) clients present during lunch were not served lunch. Clients indicated the facility serves dinner, but they have to purchase their own snacks and meals using their food stamps, as the facility does not serve sufficient food.

RECORD REVIEW: During today's visit, the LPA conducted a file review for all five (5) clients and four (4) staff. Client records were reviewed for but not limited to: medical records, admissions agreement, and consent forms. All client files reviewed were sufficient. LPA reviewed staff files for documents including but not limited to: training records, TB clearance, health screening, training records. Staff files reviewed contained all required documents. Administrator’s Certificate is pending renewal at this time.

MEDICATIONS: Beginning at 02:47 p.m., LPA reviewed medications for three (3) clients. Two (2) of three (3) clients reviewed did not have all medications written on their centrally stored medication and destruction

Report Continued on LIC 809-C

EMERGENCY DISASTER PLAN/INFECTION CONTROL: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. The LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually as required. Emergency drills are conducted quarterly; the last fire/earthquake drill was conducted on 03/20/2026.

INTERVIEWS: During today's visit, the LPA interviewed the one (1) staff present and four (4) clients. Other than the food, no concerns were noted.

LPA previously requested the LIC 500 and the LIC 610D be sent via email. To date, the LPA has not received the requested documents. Facility staff will follow up with the Administrator/Licensee regarding the documents.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D). The facility staff was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report issued.