The facility’s fire clearance is approved for six (6) non-ambulatory residents, ages 60 and over, of whom one (1) may be bedridden. The facility also maintains a hospice waiver for six (6) residents.

At the time of the inspection, two (2) residents were receiving hospice care.

Facility Tour & Observations:

Personal Rights postings (LIC 613C and Ombudsman), the Complaint Poster (PUB 475), and the nondiscrimination notice were observed posted in a common area. Residents had access to personal space, privacy, and adequate storage for personal belongings. No firearms or weapons were present at the facility. Oxygen signs were posted within the home.

Physical Plant:

The facility is located in a residential neighborhood and consists of a single-story home with five (5) resident bedrooms, two (2) bathrooms, a living room, family room, kitchen/dining area, an attached garage with a caregiver corridor, a front yard, and a backyard. All residents observed contained the required furnishings, including a bed, mattress, linens, dresser, chair, and adequate lighting. LPA observed that sharps, cleaning supplies, and other toxic substances were inaccessible to residents. Sharps were stored in a secured kitchen cabinet. Cleaning supplies were stored in the locked laundry room and a secured kitchen cabinet beneath the sink. Bathrooms were clean and equipped with required safety features, including grab bars near toilets and bathing areas and non-skid mats. Toilets, sinks, and bathing fixtures were operational. The hot water temperature was outside the required regulatory range of 105°F–120°F. Extra linens and towels were available and stored in hallway cabinets. Smoke and carbon monoxide detectors were tested and found to be operational. Fire extinguishers were observed and available. No bodies of water were present on the premises. Passageways and exits were clear and unobstructed. The front and backyard areas were maintained and contained shaded seating areas for residents’ use. (continue on 809C)

• 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.

Refrigerators and freezers were maintained at appropriate temperatures, with refrigerators observed at or below 40°F and freezers at 0°F. The facility maintained at least two (2) days of perishable food and seven (7) days of non-perishable food. Fresh produce, proteins, and dry goods were available for resident use.

Health-Related Services & Records:

Three (3) resident files were reviewed and contained required documentation, including Admission Agreements, signed consents, Physician’s Reports documenting ambulatory status, and Resident Rights acknowledgments. During record review, LPA observed that R1’s Physician’s Report documented that R1 was admitted with a gastrostomy tube (G-tube), which is a prohibited health condition.

Medications and medication records for three (3) residents were reviewed. Medications were centrally stored and secured in a locked cabinet inside the locked kitchen pantry. During the medication review, LPA confirmed that R1’s medications were administered through the G-tube.

Disaster Preparedness:

The most recent fire/earthquake drill was conducted on October 5, 2026, and corresponding drill logs were available for review. The LIC 610D Emergency Disaster Plan was available for review. Emergency supplies, including water, food, flashlights, batteries, and first aid supplies, were observed and available for use in the event of an emergency.

Personnel Records & Training

Three (3) staff files were reviewed and included criminal record clearances, CPR/First Aid, required training and TB screenings.

An exit interview was conducted with Paul Shay . During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided.