The LPA and 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 is a single-story home located in a residential neighborhood.

COMMON AREAS: This includes the family room, living room, open office and dining room. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 1:22 p.m., hardwire combination of smoke / carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguishers (x3) were observed and fully charged on 05/15/2026. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 07/02/2026 and are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. Auditory alarms at the entrances and exits were observed and functional at the time of the visit. LPA observed surveillance cameras installed in the common areas of the facility. The Administrator presented the live monitoring screen to the LPA, confirming that all cameras were functioning properly and that none of them were equipped with audio capability.

Report Continued on LIC 809-C PAGE 2...

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 (06/01/2026) as required. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard.

MEDICATIONS: Medication review began at approximately 3:10 p.m. Medications are centrally stored and locked in a cabinet in the dining room adjacent to the kitchen. Medications for two (2) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were properly documented on the centrally stored medications and destruction record, stored, locked and inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed. No errors observed during review. 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.

DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster, and LIC 9020A Resident roster. The Administrator informed LPA that they currently do not have liability insurance and have submitted all the required documentation and plan to be insured by August 2026 but will keep LPA updated.

At the time if the visit the LPA reviewed the facilities contact information on file including phone numbers, email and annual fees. Administrator confirmed that all information is accurate. LPA informed Administrator that annual fees are due. Administrator stated they plan to pay their fees this week. At the time of the visit LPA emailed the Administrator their PIN along with instructions on how to pay fees online.

Additionally LPA discussed reporting requirements with Administrator and informed them of the regulation. Technical advisory.

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.

• 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.

LAUNDRY ROOM: LPA observed the locked laundry room adjacent to the kitchen. Laundry room has a washer and dryer and locked cleaning supplies directly above in locked storage cabinets.

BACKYARD: The entire property is fenced. The backyard has an umbrella for shade with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed two (2) self-latching gates. There were no bodies of water noted at the time of the visit. There is a locked storage shed in the back yard inaccessible to residents. Only one (1) pathway is used as an emergency exit which was free of obstructions at the time of the visit. LPA observed a pile of supplies including but not limited to wheel chairs, walkers, and wood that were off the the left corner of the house. Administrator stated they have a scheduled pick up at the end of the month 07/31/2026. Technical advisory given.

GARAGE: LPA observed the detached facility garage, which was locked and contained supplies such as incontinent supplies, extra furniture, and person protection equipment (PPE).

RECORDS: Resident Records were reviewed beginning at 11:30 a.m. Four (4) 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. During the review LPA discovered that Resident #1 (R1) was admitted to the facility on 09/01/2025 with a Prohibited Health Condition (PHC) of a G-tube which poses an immediate health, safety or personal rights risk to persons in care. R1 does not have an exemption on file. Additionally R1 currently has multiple Deep Tissue Injuries (DTI) which is also PHC. Administrator informed LPA that R1 recently returned from Skilled Nursing Facility (SNF) on 06/09/26 with the DTI after being in the hospital for about four (4) months. Administrator stated that R1 has a scheduled surgery on 07/22/2026 where they will recover at a SNF and during that time will submit the required documents to CCL. LPA discussed with Administrator what was required to submit an exemption and at the time of the visit emailed a list of the required items.

Personnel Records 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. At the time of the visit LPA conducted a business search to ensure the Business / LLC is in good standing. Report Continued on LIC 809-C PAGE 4...

INTERVIEWS: Starting at 10:11 a.m. and throughout the visit one (1) staff and two (2) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit.

BEDROOMS: There are six (6) total bedrooms in the facility; four (4) bedrooms are designated as resident rooms; two (2) private , and two (2) shared and two (2) staff rooms. The staff rooms are kept locked at all times and observed to be occupied by staff. Two (2) out of four (4) 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 (1) is designated as a shared / common resident restroom, One (1) is designated as a private resident restroom, One (1) is designated as guest restroom, and one (1) is designated as a 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 115.5 - 116.1 degrees Fahrenheit, all within the required range. LPA observed storage space closets in the hallway containing extra clean linens and towels for resident use.

KITCHEN: The LPA inspected the kitchen/food service area. Knives and sharps were observed in a locked drawer. 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 116.3 degrees Fahrenheit. Cleaning supplies and other chemicals are kept in the laundry room locked and inaccessible to residents in care.

Report Continued on LIC 809-C PAGE 3...