Facility Evaluation Report

While at the facility conducting investigation (Complaint Control Number 15-AS-20260503133940) and upon review of records, inspection and interviews, Licensing Program Analyst (LPA) Delmundo observed the following:

1. Scissors in the kitchen and in the tray in the dining area.

2. Unlocked storage for cleaning supplies and ointment out in the open in the backyard.

3. Staff assisted one resident to the bathroom and left other residents unsupervised in the common area. LPA verified, and this staff stated not calling the other staff to supervised the other residents.

4. Resident's (R1) medications that were filled in March 2026 and April 2026 were not listed in LIC622 Centrally Stored Medication and Destruction Record.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds . A $250.00 civil penalty is cited f o r section 87309(a) f or repeat violation within 12 month period. Failure to submit proof of corrections by plan of correction due dates and repeat violations of other deficiencies may result in additional civil penalties.

Deficiencies, civil penalty and plan and proof of corrections were discussed with the staff.

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty, LIC9098 Proof of Correction form and copy if this report provided