Routine inspection·August 12, 2025

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Anne Walsh, executive director of the facility, and explained the purpose of the visit. There are eighty (80) residents in total residing in the assisted living and memory care portions of the facility. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of one hundred and forty-three (143) residents, ninety-five (95) of whom many be non-ambulatory, eight (8) of whom may be bedridden, and a hospice waiver approved for eight (8) residents. A request for fifteen (15) total hospice residents has been submitted to licensing, and will be updated. The facility consists of two campuses, one (1) for memory care and one (1) for assisted living. Assisted living is two (2) stories with 44 bedrooms, 2 communal showers, activity rooms, medication room, offices, a main kitchen, and a dining room. The memory care campus is a single-story building with 22 bedrooms with private bathrooms, activity room, kitchen, medication room and dining room. For Assisted Living, LPA inspected three (3) rooms in the North Station, three (3) rooms in South Station, and three (3) resident rooms in the memory care building. All bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, skid matt/strips and shower chair. All eleven (11) bathrooms tested had a hot water temperature measured between 105 – 120 degrees Fahrenheit. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has fully charged fire extinguishers kept throughout the facility. Operational Requirements: · The Program Design was reviewed. · Fire clearance was approved by LA County Fire Department for one hundred and forty-three (143) residents, ninety-five (95) of whom many be non-ambulatory, eight (8) of whom may be bedridden, and a hospice waiver approved for eight (8) residents · Care and supervision to meet the clients’ needs was observed. Staffing: · Sixty-three (63) employees provide care and supervision to the clients. Personnel Records/Staff Training: · Five (5) staff files were reviewed for criminal background clearance and training. · All Five (5) staff records reviewed have a health screening with a Tuberculosis clearance, and five (5) staff have First Aid/CPR trainings that are active. · The administrator’s certificate expires on 2/22/2025. Resident Rights/Information: · Active Physician orders were reviewed for eight (8) residents. · Medications were also reviewed for eight (8) residents. Resident Records/Incident Reports: · Six (6) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. Disaster Preparedness: · Emergency and Disaster Plan was in the facility. · The last emergency and disaster drill was conducted on 7/5/2025. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed. Exit interview held and a copy of the report will be emailed to the executive director.