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Type of visit: Required - 1 Year

Unannounced annual visit made out to this facility on 09/22/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Brandi Vargas. The Licensee, Jamie Vargas, arrived shortly thereafter to this facility while this LPA was conducting this annual visit. Brief interview was conducted with the facility designated Administrator Brandi Vargas at this time. Current census was 4 residents. It was learned that there were (3) residents under the care of hospice at this time. This facility was approved for a hospice waiver to be able to accept and retain up to (6) residents under hospice care at any given time. A tour of this facility was conducted. Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Brandi Vargas. The administrator certificate was due to expire on 09/01/024 and in compliance at this time. Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet, located in the kitchen area, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator. This medication cabinet was observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Hot water temperature was taken and measured to make sure that it was within the allowed range of 105-120 degrees. Linen closet, located in the hallway, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time. Garage area was toured. This area also housed the washing machine and dryer for this facility's use at this time. Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time. Fire extinguisher, located in facility kitchen area, was observed to have been annually inspected on 06/22/2023 by the local fire extinguisher company, USA Stanislaus Fire, and in compliance at this time. Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted. It was observed that there was a shed present on facility grounds at this time. It was observed to be locked and made inaccessible to the residents at this time. A review of (4) facility resident records was conducted. A review of (3) facility staff records was conducted. The following forms and documents were requested to be updated and submitted into CCL: LIC 308 LIC 400 LIC 500 LIC 610 The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal Rights were printed and a copy was given to the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Sep 22, 2023

Type of visit: Post Licensing

Unannounced post licesning visit made out to this facility on 12/29/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Brandi Vargas. Brief interview was conducted with the facility designated Administrator at this time. Current census was (1) resident. It was learned that there weren't any residents under the care of hospice at this time. This facility does have a waiver to accept and retain up to (6) residents under hospice care. Tour of the facility was conducted. Kitchen area was toured. Cabinets and drawers were reviewed to make sure that there was a sufficient supply of plates, silverware, and items necessary to meet the needs of the residents at this time. A review of the facility food supply was conducted to make sure that there was an adequate 2-day perishable and 7-day nonperishable amounts at all times. Pantry area was toured. Cleaning supplies and agents were observed to be present under the kitchen sink cabinet and were locked and made inaccessible to the residents at this time. Dining area, living area, and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time. Fire extinguisher, located hanging in garage entry way, was observed to have been annually inspected on 04/04/2022 by the local fire extinguisher company, USA Stanislaus Fire, and in compliance at this time. A tour of the facility resident rooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. A tour of the facility resident restrooms was conducted. Grab bars and non skid mats were observed to be in place and able to serve the needs of the residents at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees at all times. Laundry area was toured. Cabinets housing detergents, bleach, and all other laundry supplies were observed to be behind a door that could be locked to make these items inaccessible to the residents at all times. A tour of the facility garage area was conducted. Cabinets housing additional items for resident use were reviewed. Additional linens, seasonal supplies, and cleaning agents were observed to be stored behind a door leading into this area that was locked to make it inaccessible to the residents at this time. Linen closet was observed to contain the necessary supplies and items in order to meet the needs of the residents at this time. Medication cabinet, located in garage entry way cabinet, was reviewed. Policies and procedures for handling, dispensing, and documentation of the resident medications were reviewed with the facility designated Administrator at this time. A review of the facility medication administration record (MAR) was conducted. First aid kit was present and observed to contain all of the required components at this time. A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gate, and exits was conducted. The following forms and documents were requested to be updated and submitted into CCL at this time: LIC 308 LIC 400 LIC 500 LIC 610 There were no deficiencies observed or cited during today's post licensing visit. Exit Interviewthe state’s words, verbatim · CDSS document, Dec 29, 2022

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Jason Lund arrived announced to conduct a Pre-licensing inspection. LPA met with applicants Brandi & Jamie Vargas and explained the reason for the visit. The facility is licensed to serve a capacity of 6 residents. LPA was allowed entry into the facility. There are no residents at this time. LPA, and applicants toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. Facility has required (7) seven- day non-perishable and (2) day- perishable supply of food. LPA observed furniture and lighting of bedrooms, bathrooms and common areas during this visit. The temperature inside the facility measured at 71*F which is within the required range of 68-85*F. The hot water temperature was measured 120.0*F which is within the required range of 105-120*F. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed the fire extinguisher(s), smoke and carbon monoxide detectors in the facility. Facility has central heating and air. LPA observed there is a centrally stored medications area locked and inaccessible to residents. LPA conducted the Component III during this visit. License pending. Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations were observed during this visit. Exit interview held, copy of report given.the state’s words, verbatim · CDSS document, Sep 15, 2022