A Peterson RCFE

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Garrett Peterson, Administrator, and informed them of the purpose of the visit. At the time of the visit, there were one (1) staff member and three (3) residents present. Facility Overview: The facility is a one-story home with (5) bedrooms and (4) bathrooms, including an attached garage. There are no known firearms on the premises. There is a fenced pool with locked gate. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility has infection control plan in file. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 107°F. Fire extinguisher located at kitchen has current inspection tag. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Continued on LIC809-C.... Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Record Review and Resident/Staff Files: LPA reviewed files for four (4) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Three (3) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for three (3) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 11-12-2025, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.the state’s words, verbatim · CDSS document, Jan 21, 2026

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:30 AM, LPA met with Licensee/Administrator Garrett Peterson & Terrye Peterson . An initial application for Change of Ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 08/01/2022 for a total capacity of six (6), five (5) non-ambulatory and one (1) bedridden residents. Fire clearance was granted on 07/01/2024. LPA Delgado observed the following: Structure: Facility was a one-story house with five (5) resident bedrooms, three (3) resident bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house. Heating/Cooling System: There are two (2) Central heating and air conditioning system installed with a panel located inside bedroom #1 and in the hallway to control each section of the house. Bedrooms: Each resident bedroom #2, #3, #4 and #5 will accommodate any non-ambulatory resident, shared bedroom #1 will accommodate one (1) bedridden residents and one (1) non-ambulatory resident. 5 resident bedrooms were adequately furnished with bed-bedroom #4 had no bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Bathrooms: Three (3) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of toilet paper, and soap. At 11:00 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 106.3 degrees Fahrenheit. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked closet next to the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. (CONTINUED ON PAGE 2) (CONTINUED FROM PAGE 1) and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the garage. Laundry detergents were observed in garage away from residents and cleaning supplies stored inside the cleaning closet next to the garage. Living/Family room: There was a living room with seating for all clients and TV. Linens and Hygiene Supplies: An adequate supply of linens was stored in a cabinet in the main hallway of the residence and hygiene supplies stored in a closet in the hallway . Yards/Outside: Patio table and chairs were observed in the backyard. There was a gate on the South side and North side of the property with a self-latching. All outdoor pathways were free of obstructions. Pool was observed with a 5 foot perimeter mesh/metal gate surrounding the pool and no fire arms will be stored on the premises. Emergency Phone Numbers, and Exit Plan: Facility sketch were observed posted in the main hallway. Ombudsman poster and Let-Us-No poster observed. General items: Three (3) fire extinguishers were charged and located in the kitchen, outdoor and garage. Seven (7) dual smoke alarms/carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the Family room. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply and food suppy was observed. Cameras located in the common areas: living room, kitchen, hallway, medication cabinet, front door and garage that record with no audio for 5 days at time. Component III is scheduled for October 16, 2024. (CONTINUED ON PAGE 3) (CONTINUED FROM PAGE 2) Pre-Licensing is incomplete and the following corrections to be resolved by 10/14/2024: Update Plan of Operation to include the cameras in the common areas Update Admission agreement to include the notification of the cameras in the common areas Request Hospice Waiver for a total of six (6) Setup bed in room #4 obtain two (2) exterior window screens obtain trash cans with lid for resident bathrooms obtain paper towel stands obtain lamp for bedroom #5 An exit interview was conducted, and a copy of this report was given.the state’s words, verbatim · CDSS document, Sep 27, 2024

Type of visit: Office

Facility Type: RCFE Application Type:CHOW Capacity:6 Census (5): COMP II Participants: Licensee/ Terrye Peterson & Administrator/ Garrett Peterson Interview Method: Telephone interview On [07/25/2024], applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jul 25, 2024