Facility Evaluation Report

On 4/24/26 Licensing Program Analyst (LPA) J. Leffall arrived unannounced for an annual inspection visit. LPA was met by Administrator (A1), Virginia Penner. LPA introduced self, explained reason for visit and was permitted entry into the facility.

LPA completed a health and safety check on residents in care. LPA toured the facility completed. Residents observed in common areas and in rooms. There was 1 resident on hospice at the time of the inspection. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Carbon monoxide detectors were present and operate on a system. Smoke Detectors were present and operational per report given to LPA by California Code of Regulations. Fire extinguisher last serviced 10/16/25. Last fire drill on 4/21/26. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Sharps, chemicals and medications were located in locked closets/rooms. Residents hot water temperature in the bathrooms were measured at a range of 114.2 to 118 in 5 bathrooms.

The following issues were observed during todays visit: 2 medications were successfully administered but not initialed by staff. Medication details located on LIC-809D for medication details. 5 out of 5 resident showers did not contain non-skid mats or strips. 3 out of 5 residents did not contain the Safeguard for Property Values form in resident files.

Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

LPA requested the following documents to be submitted to CCL by 3/6/25: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Personnel Report (LIC 500), Receipt for Liability Insurance coverage, Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Exit interview conducted. A copy of this report with Appeal Rights were distributed to Administrator whose signature confirms signature of receipt.