INTERVIEWS: Starting at 9:33 a.m. and throughput the visit one (1) staff and one (1) resident interview were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit.

COMMON AREAS: This includes the 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 2:37 p.m., hardwire combination of smoke, carbon monoxide detectors and fire door were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 07/15/2026. 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. Activities were observed in the common areas. 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...

• 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 three (3) total bedrooms in the facility; two (2) bedrooms on the first floor (designated for residents) and one (1) bedroom upstairs for the operators/staff. Of the two (2) resident bedrooms one (1) is designated as private, single occupancy, resident room and one (1) is designated as a shared double occupancy resident room. At the time of the visit both rooms were set up as private single occupancy resident rooms. The upstairs staff room and area is kept locked at all times. The stairway leading to the staff area and staff room is locked with a gate. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are two (2) total restrooms in the facility of which one (1), on the first floor is designated as a shared / common resident restroom, and one (1), on the second floor is designated as a staff restroom. Resident restroom was observed to be equipped with a slip resistant mat. Grab bars were observed in the restroom. The restroom was sufficiently stocked with supplies and paper towels. The hot water temperature was measured in the resident restroom and measured 117.1 degrees Fahrenheit, within the required range. LPA observed storage space closets in 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 118.1 degrees Fahrenheit. Cleaning supplies and other chemicals are kept under the sink and garage locked and inaccessible to residents in care.

BACKYARD: The entire property is fenced. The backyard has a patio area with an umbrella for shade, patio furniture including a table and chairs for resident use. LPA observed the backyard of the facility to contain a pool that was completely fenced and locked at the time of the visit. All passageways were observed to be clear. LPA observed two (2) self-latching gates. There are two (2) locked storage sheds in the back yard inaccessible to residents. Only 1 (one) pathway is used as an emergency exit which was free of obstructions at the time of the visit. Report Continued on LIC 809-C PAGE 3...

GARAGE: The garage is detached to the house and remains locked at all times. The laundry room containing a washer and dryer are inside the garage. Detergents, disinfectants, and cleaning supplies observed locked and inaccessible in the garage. LPA observed an adequate amount of emergency food and water.

RECORDS: Resident Records Two (2) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Pre- admission appraisal, 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 Five (5) 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. During the review LPA discovered that two (2) of five (5) staff were missing proof of their initial 40 hour training and their 6 hours of hands on medication training which poses a potential health and safety rights risk to persons in care. At the time of the visit LPA conducted a business search to ensure the Business / LLC is in good standing ; LLC is Active and in good standing.

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. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard. The last emergency disaster drill took place on 6/12/26 and are conducted quarterly. The emergency disaster plan was reviewed on 6/12/2026 and the infection control plan was reviewed on 6/25/26.

MEDICATIONS: Medication review began at approximately 12:23 p.m. Medications are centrally stored and locked in a cabinet in the dining room adjacent to the living room. Medications for two (2) residents were reviewed. Medications are labeled and checked for expiration dates. During the review LPA discovered that one (1) out of two (2) residents medications were not properly documented on the centrally stored medications and destruction record(CSMDR). Six (6) out of seventeen (17) medications were not documented on the (CSMDR) which poses an immediate health and safety rights risk to residents in care. 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 809-C PAGE 4...

DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster, LIC 9020A Resident roster and copy of the Limited Liability insurance.

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.