Golden Living Guest Home

Type of visit: Case Management - Deficiencies

On 05/26/2026 at 10:45 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Caregiver, Thazin Lwin, and explained the purpose of the visit. Thazin phoned the Administrator, Jezrael Pascual, to inform. Ms. Pascual arrived shortly after. LPA was unable to conduct a Plan of Correction (POC) visit within the required compliance time frame. Therefore, deficiencies that have not been cleared are being re-cited, and repeat civil penalties are being assessed, as applicable. Deficiencies Cleared: CCR 87202(a)(2) – Cleared on 02/12/2026. CCR 87307(a)(2)(C) – Cleared on 02/23/2026. CCR 87623(b) - Cleared 03/31/2026. CCR 87609(b)(4) - Cleared 04/30/26. CCR 87628(a) - Cleared 04/30/26 LIC809-C (Page 2) Continued... Deficiencies Not Cleared: CCR 87463(a) CCR 87608(a)(3) CCR 87507(e) Repeat Civil Penalties $250.00 x's 3 = $750.00 The deficiencies were observed during today's visit and are cited on the attached LIC 809D pursuant to California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. Appeal Rights, LIC421FC and a copy of this report provided.the state’s words, verbatim · CDSS document, May 26, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jun 9, 2026

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidence by: Based on record review and interview, the licensee did not comply with the section cited above by having completed Appraisal Needs and Services (ANS) on file for R4 and R5 which poses an health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Administrator to send ANS for R4 and R5 updated with change of condition (hospice and bedridden) and signed to CCLD by POC due date. Repeat Civil Penalty $250.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(e) · Plan of correction due date: Jun 9, 2026

87507 Admission Agreements (e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. This requirement is not met as evidence by: Based on record review and interview, the licensee did not comply with the section cited above by not having an signed Admissions Agreement on file for R4 and R5 who were transferred from another facility which poses an health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Administrator agreed to send a copy of signed Admission Agreements for R4 and R5 to CCLD by POC due date. Repeat Civil Penalty $250.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Jun 9, 2026

87608 Postural Supports (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement is not met as evidence by: Based on observation, record review and interview, the licensee did not comply with the section cited above by not having an doctor's orders on file for R1, R2 and R3 which poses an health, safety or personal rights risk to persons in care. This requirement is not met as evidence by:the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Administrator agreed to submit doctor's orders for postural/mobility support for R1, R4 and R5 to CCLD by POC due date. Repeat Civil Penalty $250.00

Type of visit: Case Management - Other

On 05/26/2026 at 2:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management regarding a capacity increase. LPA met with Administrator, Jezrael Pascual, and explained the purpose of the visit. LPA toured the facility with Administrator to view the floor plan for the requested capacity increase for 6 Residents. LPA observed rooms During the visit deficiencies observed: Pile of wooden drawers, materials located on front sidewalk Unlocked door to laundry room with toxic chemicals unlocked: mulit-purpose disinfectant, Zep Drain Care solution, Downy Fabric Softener, Arm and Hammer Laundry Detergent. Resident/Staff coming upstairs to unlicensed area and sleeping upstairs without approved fire clearance. Community Care Licensing was not informed of hospice services for R5. In addition, R4 and R5 are both in shared room and there's no agreement on file that R4 grant access to the shared living space to hospice caregivers. LIC809-C (Page 2) The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights, LIC421IM and a copy of this report provided.the state’s words, verbatim · CDSS document, May 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: May 27, 2026

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidence by: Based on observation, file review, interview, the licensee did not comply with the section cited above by not having an approved fire clearance upstairs before letting residents (R2) go upstairs, sleeping in bedroom in which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Administrator will redirect resident(s) to first floor licensed area for sleeping and taking space. Administrator will self-certify that they have read the regulation and will comply moving forward. Administrator will send self-certification to CCLD by POC due date. Immediate Civil Penalty $500.00

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: May 27, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidence by: Based on observation the licensee did not comply with the section cited above by not having the laundry room door locked upstairs which toxic chemicals: Laundry detergent, Downy Softener, multi-purpose disinfectant, drain cleanser were unlocked in laundry room. In which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Administrator agreed to conduct an In-Service Training with staff and send sign-in sheet to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 9, 2026

87303 Maintenance and Operations (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Based on observation, the licensee did not comply with the section cited above by not having piles of wood debris cleared from front yard which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Administrator agreed to clean up piles of wooden debris from front yard/sidewalk and send a photo to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87632(d)(2) · Plan of correction due date: Jun 9, 2026

CCR 87632 Hospice Care Waiver (d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. Based on observation, record review and interview the licensee did not comply with the section cited above by not notifying CCLD of R5 hospice care which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Administrator sent hospice notification to CCLD for R5 during visit. Deficiency cleared during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(b) · Plan of correction due date: Jun 9, 2026

87633 Hospice Care of Terminally Ill Residents (b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: Based on record review and interview the licensee did not comply with the section cited above by not having a signed hospice care plan on file for R5 which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Administrator agreed to submit an signed hospice care plan for R5 to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633(h)(5) · Plan of correction due date: Jun 9, 2026

87633 HospiceCare of Terminally Ill Residents (h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident’s record: (5) A statement signed by the resident's roommate, if any, or any resident who will share a room with a person who is terminally ill to be accepted or retained as a resident, indicating his or her acknowledgment that the resident intends to receive hospice care in the facility for the remainder of the resident's life, and the roommate's voluntary agreement to grant access to the shared living space to hospice caregivers, and the resident's support network of family members, friends, clergy, and others. Based on record review and interview the licensee did not comply with the section cited above by not having a signed statement agreement on file for R4 whom shares room with R5 which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Administrator agreed to get a signed statement from R4's responsible party and send to CCLD by POC due date.

Type of visit: Required - 1 Year

On 04/14/2026 at 10:10 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Jezrael Pascual and explained the purpose of the visit. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured a t116.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 01/19/2026. Emergency Disaster Plan was last posted on 04/14/2026. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 03/01/2026. LPA reviewed 5 residents records and 5 staff records. LPA also reviewed a sample of resident’s medications. The following documents were reviewed during the visit: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan, Liability Insurance, and Current Administrator’s Certificate. ***CONTINUE ON 809C*** ***CONTINUE FROM 809*** THE FOLLOWING DEFICIENCY WAS OBSERVED: · At 12:05 PM, LPA checked five resident records (S1-S5). Resident 2 (S2), Resident 3 (S3) and Resident 4 (R4) did not have a signed and completed admission agreement on file. The above deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 14, 2026

Type of visit: Case Management - Other

On 02/11/2026 at 3:00 pm, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Licensee/Administrator, Thinn Aye, and explained the purpose of the visit. While conducting complaint investigation 15-AS-20260204142916 on 02/11/2026, LPA conducted a record review and facility observations. During the visit, LPA observed that Resident 1 (R1) was residing in a room that does not have fire clearance for a bedridden resident. LPA also observed that the bedroom of Residents 2 (R2) and 3 (R3) was being used as a passageway to access the room where R1 is currently located. Additionally, LPA observed the following: Residents 1 through 6 (R1–R6) did not have completed Appraisal Needs and Services documents on file. Residents 4 (R4) and 6 (R6) did not have updated Admission Agreements on file. One-half bed rails were in use for Residents 1 through 4 and Resident 6 (R1–R4, R6) without physician’s orders on file. Home health care plans were missing for Residents 1 (R1) and 2 (R2). Resident 6 (R6) eloped on 12/11/2025. LPA received a copy of the Unusual Incident Report that Licensee Thinn Aye stated was submitted to CCLD. LIC809-C Continued... LIC809-C (Page 2) LPA obtained the following documents: updated facility sketch. Deficiencies were observed and cited in accordance with the California Code of Regulations, Title 22 (see LIC 809D). Failure to correct the deficiencies may result in civil penalties. An exit interview was conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 11, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Feb 12, 2026

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons This requirement is not met as evidence by: Based on observation, file review, interview, the licensee did not comply with the section cited above by not having a fire clearance for bedridden (R1) in a room that wasn't cleared as a bedroom per facility sketch and current fire clearance dated 10/24/22 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: Administrator agreed to submit an updated facility sketch that will include all bedrooms and bedridden. In addition, Administrator will submit notification to local fire district of bedridden resident in facility. All copies of documents will be submitted to CCLD by POC due date. Immediated Civil Penalty $500.00 assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(a)(2)(C) · Plan of correction due date: Feb 26, 2026

87307 Personal Accommodations and Services (a) Living accommodations...shall be related to the facility's function. ... provide comfortable living accommodations and privacy for the residents... The following provisions shall apply: (2) Resident bedrooms shall be provided which meet... (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met as evidence by: Based on observation, the licensee did not comply with the section cited above by allowing the use of R2's and R3's bedroom as a passageway to another room for R1 which poses an health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: Administrator agreed to read the regulation and self certify understanding the regulation. Administrator stated that they will lock the sliding glass window that is connected between Bedroom #3 and adjacent room. Documents will be sent to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Feb 26, 2026

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidence by: Based on record review and interview, the licensee did not comply with the section cited above by having completed Appraisal Needs and Services (ANS) on file for R1-R6 which poses an health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: Administrator agreed to complete ANS for R1-R6 and send completed signed copies to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(e) · Plan of correction due date: Feb 26, 2026

87507 Admission Agreements (e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. This requirement is not met as evidence by: Based on record review and interview, the licensee did not comply with the section cited above by not having an updated Admissions Agreement on file for R4 and R6 who were transferred from another facility (same Licensee) which poses an health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: Administrator agreed to submit copies of updated signed admission agreements for R4 and R6 and will submit to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Feb 26, 2026

87608 Postural Supports (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement is not met as evidence by: Based on observation, record review and interview, the licensee did not comply with the section cited above by not having an doctor's orders on file for R1, R2 and R3 which poses an health, safety or personal rights risk to persons in care. This requirement is not met as evidence by:the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: Administrator agreed to submit doctor's orders for postural/mobility support for R1, R2 and R3 to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87623(b) · Plan of correction due date: Feb 26, 2026

87623 Indwelling Urinary Catheter (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (1) Ensuring that insertion and irrigation of the catheter shall be performed by an appropriately skilled professional. This requirement is not met as evidence by: Based on observation, record review and interview, the licensee did not comply with the section cited above by not having the home health care plan on file for R2's foley catheter and caregiver training with draining the catheter bag which poses an health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: Administrator agreed to submit a copy of home health care plan for R2's foley catheter and training record for staff caregiversby skilled health professional to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87609(b)(4) · Plan of correction due date: Feb 26, 2026

87609 Allowable Health Conditions and the Use of Home Health Agencies (b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s). This requirement is not met as evidence by: Based on record review and interview, the licensee did not comply with the section cited above by not having a home health care plan on file for R1's wound care including but not limited to physical therapy, occupational therapy and nurse aide which poses an health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: Administrator agreed to submit a home health care plan for R1's wound care and submit to CCLD by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR87628(a) · Plan of correction due date: Feb 26, 2026

(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidence by: Based on record review and interview, the licensee did not comply with the section cited above by not having an appropriately skilled professional administering insulin injections for R1's diabetes which poses an health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: Administrator agreed to submit an updated Physician's Report (LIC602-A) for R1 showing that they can administer their own insulin injections or documentation that an appropriately skilled professional to CCLD by POC due date

Allegation investigated: Staff physical abused resident Staff verbally abused resident

On 12/16/25 at 1:30 PM Licensing Program Analyst (LPA) Gregory Clark arrived unannounced to deliver findings in regard to the allegations above. LPA spoke with Thinn Aye, Administrator (ADMIN) and informed her of the reason for the visit. ADMIN gave permission for care staff Htake Win to sign the report. During the course of investigation LPA interviewed R1, facility staff, Administrator at R1’s current placement, R1’s Center for Elders Independence Social Worker (SW) and R1’s Occupational Therapist. LPA also reviewed R1's file. R1 was placed at the facility by her social worker on July 23, 2025, after being transferred from her assisted living apartment due to a decline in condition requiring 24-hour care. Review of R1’s file and interviews with staff indicated that R1 was unhappy with her placement and frequently refused care. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** Documentation and staff statements also noted that R1 was often combative and physically aggressive with staff. Staff reported multiple incidents in which R1 scratched, hit, or attempted to strike caregivers. The Administrator provided photographs of scratches on staff members’ arms reportedly caused by R1. Interviews with all staff involved revealed that no staff member witnessed R1 being physically abused or yelled at by staff. Staff denied the allegations and stated that they continued to attempt care despite R1’s refusal and combative behavior. Records showed that R1 had called 911 on several occasions accusing staff of physical abuse and yelling; however, no evidence was found to substantiate these allegations. LPA interviewed R1 at CEI in Concord. R1 was pleasant and talkative during the interview and shared various personal stories. When asked about her stay in Oakland, R1 shook her head, frowned, and stated, “I forget now.” R1 recalled one incident in which a staff member allegedly pushed a walker into her leg, causing a bruise, but she was unable to provide additional details regarding the date, staff involved, or surrounding circumstances. This agency has investigated the above complaint. We have found that the complaint was unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 15-AS-20251022165415

Type of visit: Required - 1 Year

On 4/15/25 at 2:15 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Thinn Aye and explained the purpose of the visit. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the kitchen sink was measured at 113.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 1/19/24. Emergency Disaster Plan was last reviewed on 4/15/25. First aid kit was observed to be complete. LPA reviewed 4 residents records and 3 staff records; all were complete. LPA also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 15, 2025

Type of visit: Required - 1 Year

On 4/10/24 at 2:00 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Thinn Aye and explained the purpose of the visit. The facility’s fire clearance was approved for 6 residents. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 105.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 1/19/24. Emergency Disaster Plan was last posted on 4/10/24. First aid kit was observed to be complete. LPA reviewed 5 residents records and 5 staff records; all were complete. LPA also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 10, 2024