Routine inspection·July 25, 2025

Licensing Program Analysts (LPAs) Quoc Huynh and Angela Barutyan arrived unannounced at 9:55AM for a required one year visit. The LPAs met with Health and Services Director (HSD) Tony Nunez and Executive Director (ED) Susan Weisbarth and explained the reason for the visit. Entrance interview conducted. At 10:30AM, the LPAs and HSD toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The facility’s kitchen was inspected and found to be in compliance with Title 22 regulations. The facility receives food deliveries four (4) times a week from different vendors. There was a sufficient supply of perishable and non-perishable food. The food in the freezer and the refrigerator were observed to be of good quality. COMMON AREAS: The facility is a one-story building that contained a lobby, offices, kitchen, storage, and employee lounge which was inaccessible to residents. The remainder of the facility had a dining room, activity room, day room, activity office, salon, medication room, and an outdoor courtyard. The LPAs observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. Areas that posed a safety risk to residents were observed to be locked. Report Continued on LIC 809-C Required postings were found in the lobby and throughout the facility hallways. There were fire extinguishers throughout the facility, which were serviced 04/28/2025 and contained emergency flashlights. The courtyard contained a raised garden bed, activities for residents, and furniture in good condition with shade. Emergency food and water were stored in an outdoor utility closet along with general storage. The LPAs also observed the emergency side exits. In the rear of the facility, the LPAs, ED, and HSD observed a window screen leaning against the building that belonged to a resident’s window above it. The ED and HSD identified the resident’s unit and had maintenance secure the window screen onto the window. RESIDENT ROOMS: Beginning at 10:40AM, the LPAs observed ten (10) randomly selected resident rooms. Appropriate furniture and sufficient lighting were observed in the units. The LPAs did not observe signal systems installed in the resident rooms. The HSD stated that resident rooms were equipped with motion sensors that detect resident movement and potential falls, however, no system is in place for residents to call for help from their room. LPAs observed some residents wearing pendant buttons which transmit signals to the facility laptop. The HSD stated that not every resident gets a pendant. The pendants currently being used identify which resident enacted the call. At 12:30PM, the LPAs and HSD tested three (3) randomly selected pendant buttons which were not operational at the time as there were no signals received by the laptop. One (1) of the pendants flashed a red light indicating it was not operational. Staff interviews revealed that response times to pendant calls have been an issue at the facility and staff have gotten multiple warnings and in-service training to improve response times. Interviews with two (2) residents revealed concerns of the facility’s signal system and staff response times. LPAs reviewed call logs for Resident #1 (R1) between 07/01/2025-07/25/2025 and observed response times ranging from 6 minutes to 2 days. There were seventy-six (76) calls total, of which fifteen (15) were accidental repeat calls by R1, making a total of sixty-one (61) calls by R1. Call logs revealed only ten (10) out of sixty-one (61) pendant calls had response times under fifteen minutes. Report Continued on LIC 809-C Resident restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Water temperature was tested throughout the units and measured between 95 degrees F and 128.5 degrees F, which is not within the required range per regulation. R1 was observed to have cleaning supplies stored under their restroom sink which included disinfectants, bathroom foam cleaner, and multi-purpose cleaner. Resident #2’s (R2) restroom vanity handle on the right bottom cabinet was observed to need repairs. The HSD stated they would check in with the facility’s maintenance to have it repaired. Resident #3 (R3) was observed to have oxygen administered and did not have signage outside their unit. The HSD confirmed R3 was receiving oxygen and had facility Staff post the signage. Resident #4 (R4) had access to two (2) electric razors in their restroom, which the HSD and ED secured during the visit. Record review revealed R1 and R3 were at risk and should not have access to these items. R3’s Physician’s Report specifically identifies R3 should not have access to razors. MEDICATION: Medication review began at 12:11PM. The LPAs reviewed medications for five (5) residents. Medications were inaccessible in locked medication carts and in the medication room. Five (5) out of five (5) resident medications reviewed were documented and stored in compliance with regulation at this time. RESIDENT RECORDS: Resident records were reviewed at 3:25PM. The LPAs reviewed five (5) files for, but not limited to: admissions agreements, medical assessments, and appraisals. Resident records reviewed were in order at this time. Due to time constraints the annual visit will continue at a later date. Three (3) Staff and five (5) residents were interviewed. No complaints noted. Pursuant to Title 22 CA Code of Regulations and/or Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D). The ED designated the HSD to sign today's report. Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.