Routine inspection·September 29, 2025

License Program Analysts (LPA) Luis De Leon conducted an unannounced annual required visit. LPA met with Administrator Mary Anne Villegas. The purpose of today’s visit was explained. The facility is licensed to serve 44 residents over the age of 60, 18 residents may be non-ambulatory. The facility is approved for 4 hospice waivers, and 6 bedridden in assigned rooms. The LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted as follows: FACILITY PHYSICAL PLANT The facility is a two-story building located in Los Angeles, CA. A tour of the facility includes: Upstairs (2nd Floor): 9 resident rooms (with private bathrooms), lobby/TV room, kitchen, dining/activity room, 2 public restrooms, janitor closet and linen closet. Downstair (1 st Floor): 13 resident rooms, 2 common shower rooms, beauty shop, library/laundry room, 2 common shower rooms, 2 staff bathrooms, nurse station (medication room), janitor closet and linen closet. REVIEW OF FILES Client record review consisted of Admission Agreements, Identification and Emergency Info, Physicians Report, Consent Report, Need and Service Plans, Personal Rights, and Centrally Store Medication. Client’s P&I money were reviewed for 2 clients. Staff record review consisted of Personnel Report, Health Screening, Criminal Record Statements, Fingerprint Clearance, Training, and CPR. Report continues on page LIC-809C... Observations during facility tour: Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPA observed that there was clean linen, bath towels, and personal hygiene with reasonable closet space available for clients. Signal System was observed in the bedroom and the bathroom. LPA tested the signal system and caregivers responded in a timely manner. Wall and floors are in good repair. Hallways and stairwells were clean and free of obstructions. Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food. Dining room has sufficient seating area. Weekly food menu is posted at the facility. The kitchen staff has modified diets posted for residents that require modified diets. Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean. The water temperature was tested and measured. It was found in compliance with Title 22 regulations between 105º and 120º F degrees. The LPA did not observe any sharps accessible to clients in their rooms or in the common areas. Also, disinfectants and cleaning supplies are locked and secured inaccessible to clients. Smoke detectors were observed in all bedrooms and common areas. Carbon monoxide detectors were observed in the hallway on both floors leading to residents’ rooms. Three (3) fire extinguishers were observed and were fully charged with last inspection on 01/13/2025. Last fire drill, earthquake, and disaster drill was conducted on 7/15/2025. There are shaded areas in front of the facility for residents to enjoy. The medications are centrally stored and locked in the nurse room. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all four (4) residents. LPA conducted interviews with one staff. One client interview was conducted while second client was out in the community. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report was provided to administrator Mary Anne Villegas.