Facility Evaluation Report

On 07/25/2025 at 1:00pm Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Tracy Lehner (cert #7005595740 Exp:8-21-26) and explained the purpose of the visit. Administrator certificate is current. LPA Benson and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to five (5) resident rooms, common areas, five (5) bathrooms, kitchen, storage areas and yard. Staff and resident files were reviewed. Not able to complete files review. Medications were also reviewed. Deficiencies were observed. Medication is locked in a locked closet. The common area was clean, odor-free and in good repair. All bedrooms had required furniture, bedding, lighting and windows with screens. The bathrooms were clean and in good repair. Deficiencies were observed. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities planned for the clients. All required postings are displayed within the facility. The pools/bodies of water on the premises is locked with the only entrance to use a key fob. No firearms are on premises. The last disaster drill was conducted and documented on 7-22-25, the facility has been conducting drills every 3 months. LPA interviewed three residents and three staff. The annual inspection was not completed due to time restraints. LPA will return to complete this inspection. The document was signed and a copy delivered to the Administrator. On 7-29-25 LPA Benson arrived at 12:30pm and completed the annual inspection with the CARES tool. The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted, a copy of the report, and appeal rights provided to administrator.