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.

INTERVIEWS: Starting at 9:35 a.m. and throughout the visit one (1) staff and two (2) resident interviews were conducted. Staff interview revealed that staff is 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. Residents stated that staff treat them well.

COMMON AREAS: This includes living room, 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 10:41 a.m. hardwire combination of smoke / carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 09/18/2025. 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. Activities were observed in the common areas. The fireplace in the dining room was adequately screened, and noted to be non-functional. There is a functioning telephone on the premises. Auditory alarms at the entrances and exits were tested and observed to be functional at the time of the visit. Report Continued on LIC 809-C PAGE 2...

MEDICATIONS: Medication review began at approximately 2:02 p.m. Medications are centrally stored and locked in the office / staff lounge adjacent to the living room. Medications for three (3) residents were reviewed. Medications are labeled and checked for expiration dates. Two (2) out of three (3) resident medications including PRNs were properly documented on the centrally stored medications and destruction record (CSMDR) which poses a potential health and safety risk to residents in care. At the time of the staff reviewed CSMDR and conducted a medication audit. 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, LIC 9020A Resident roster. Administrator emailed LPA a copy of the Limited Liability insurance and the emergency disaster plan.

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.

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.

LAUNDRY ROOM: LPA observed the locked laundry room adjacent to the office / staff lounge. Laundry room has a washer, dryer, laundry detergent and locked cleaning supplies.

OFFICE: LPA observed the office which is adjacent to the living room. The office was observed to be locked and inaccessible to residents in care. The office was observed to contain locked cabinets that contained resident medications and facility files. Additionally, the office contained a locked refrigerator for resident medications and the facility’s complete first aid kit. LPA observed an additional fire extinguisher mounted on the wall to be serviced on 09/18/2025.

Report Continued on LIC 809-C PAGE 4...

• 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.

BEDROOMS: There are five (5) total bedrooms in the facility; four (4) bedrooms are designated as private, single occupancy, resident rooms and one (1) is designated as a shared, double occupancy resident room. There is no staff room and Administrator stated that staff remain awake at night. All five (5) bedrooms 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, chair/s and closet space. The beds are furnished appropriately. 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 two (2) total restrooms. One (1) is designated as a shared / common resident restroom and One (1) is designated as a private resident 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 119.8-120 degrees Fahrenheit, all within the required range. LPA discussed the regulatory standard of 105 -120 degrees Fahrenheit with Administrator as the water temperature was at the maximum. At the time if the visit Administrator adjusted the water temperature to ensure it was slightly below 120. LPA observed storage space closets in the laundry room 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 119.9 degrees Fahrenheit. Cleaning supplies and other chemicals are kept locked under the sink locked and inaccessible to residents in care. At 10:02 a.m. LPA observed a razor, and nail polish in an unlocked drawer in the kitchen, after review of all six (6) residents physician reports four (4) of six (6) residents physicians indicate that the following items could pose a danger which poses a potential health and safety risk to residents in care.

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