Beginning at 9:50 A.M., the LPA, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Please note: the facility is a 2-story house; the upstairs area is inaccessible to residents in care and is used for staff only, therefore was not observed. The following was observed in the downstairs area:

Hardwired combination smoke and carbon monoxide detectors were tested at 11:30 A.M. and were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 02/20/2024.

BEDROOMS: There are 3 (three) total bedrooms, all of which are designated for shared resident use. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. LPA observed that all exterior exit doors of resident's rooms were locked at the time of the visit.

RESTROOMS: The LPA observed 2 (two) restrooms in the facility; 1 (one) is for shared use and 1 (one) is designated for private resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Between 10:04 A.M. and 10:16 A.M., hot water temperature was measured in both restrooms and measured within the required range.

Continued on LIC 809-C

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be inaccessible to residents in care. The facility maintained a comfortable temperature of 70 degrees. LPA observed a ring doorbell, administrator did not know that a waiver is required to have ring doorbell. LPA did not cite but advised the licensee to submit a waiver for the Ring doorbell due to the audio component, to update plan of operation and admission agreement. LPA observed cameras throughout the common areas only. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed.

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. Facility has a side gate observed to be self-closing and self-latching gate with clear passageways for emergency exit use. All exits and passageways were observed to be free of hazards. The facility does contain a pool, which was observed to be gated and locked in compliance with regulation at the time of the visit.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on product labels. Knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. At 10:13 A.M. hot water measured at 109 degrees Fahrenheit.

Garage/Laundry room: The facility has a laundry room. The laundry room leads to the garage where cleaning supplies and disinfectants are kept. LPA observed extra food and additional PPE supplies are stored. The Garage remains locked and inaccessible to the residents in care.

Continued on LIC 809-C

MEDICATION REVIEW: Medications review began at approximately 1:10 P.M. Medications are centrally stored and locked in a file cabinet inside a pantry in the kitchen area. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications for all residents were observed. LPA observed that hospice Resident #2 (R2) has a G tube. Administrator stated that staff will feed and administer medication to R2 daily as prescribed. Hospice care plan signed on 08/09/2024 states that hospice responsibility is to manage any hospice-related medications that must be given by injection/infusion. All other residents' medications were observed to be maintained and administered in compliance with regulation at the time of the visit.

During today's visit, LPA gathered the following items: LIC 500 and a copy of the facility's liability insurance. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, at the time of the visit. Emergency drills are conducted quarterly, with the last drill documented on 11/05/2024.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or CA Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.