Routine inspection·June 3, 2025

Licensing Program Analysts (LPAs) Alberto Lopez, Elena Mallett, and Sakinah Madyun conducted an unannounced annual inspection visit. LPA met with Maria Vasquez, Nursing Manager who assisted with the visit. The facility was licensed to serve one hundred & twelve (112) non-ambulatory residents, ages 60 and above. The facility had an approved five (5) hospice waivers. Administrator certificate was current with expiration date on 09/12/2025. Currently there are 56 residents. Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and have an infection Control Plan at facility. Operational Requirements: The facility does accepts patients with dementia There 0 bedridden residents residing at the facility. The facility has the sufficient amount of liability insurance covering injury to residents and guest. Physical Plant & Environment Safety: The facility is located in a residential neighborhood, consists of three (3) buildings with fifty-six (56) resident apartments. The facility has six (6) administrative offices, a reception area/lobby, beauty salon, wellness center, three (3) libraries, coffee/reading room, hospitality room, dining room, kitchen, mail room, communication room, activity /game room/painting/card making room, general store, housekeeping storage room, computer lab, nurses station, bingo room, exam room, staff lounge, and recovery room. There are multiple storage closets/rooms and an indoor/ outdoor activity area. The facility has fifteen (15) public restrooms, four (4) residential laundry rooms and a maintenance laundry room. Resident rooms consist of a bedroom, living room, dining area, kitchen, bathroom and walk-in closet. Bathrooms are clean and operable with grab bars and non-skid surface mats/strips. Hot water temperature was in a range of 109.5 to 129.9 degrees Fahrenheit which is not within range of 105.0 -120.0 degrees F. Adequate linen and personal hygiene supplies are in stock. (Continued on 809C) Staffing : There appears to be sufficient staffing at the facility. Staff employed are all over the age of 18. Personnel Records-Training : Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Identification & Emergency Information, Original Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. Admission Agreements and Physicians reports. Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Visiting hours are posted. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. Food Service: There are sufficient food supplies of 2-day perishable and 7 day non perishable food. The food is properly stored in the refrigerator to avoid cross contamination. Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed 5 residents' medication, and most medication is administered according to doctor’s orders. Most all the over-the-counter medications did not have labels, and the aspirin was being shared with other residents in the community. and one resident’s was prescribed medication for 5 consecutive days and there is no documentation that was provided as ordered. Disaster Preparedness: The facility has an Emergency Disaster Plan but requires updating. Residents with Special Health Needs: There are no residents with special health needs at facility. Deficiencies cited and technical advisory provided. Exit interview conducted with Maria Vasquez and copy of report, 809D and appeal rights provided.