Routine inspection·January 15, 2026

Licensing Program Analysts (LPAs) Angela Barutyan and Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 09:35AM. LPAs were greeted by staff and Executive Director (ED) Brian Larios. At 10:11AM, the LPAs, along with the ED and Maintenance Technician John Dasilva toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: FACILITY LAYOUT: The facility is one building with four (4) floors of which three (3) floors contain resident rooms. The fourth level is a rooftop area and there is a basement floor containing a theater. The facility has one hundred thirty-one (131) units. The first floor contains the Memory Care Unit and has four (4) delayed egress doors. There are twenty-six (26) resident rooms in the Memory Care Unit and five (5) rooms are shared. BEDROOMS: The LPAs toured a total of ten (10) resident rooms. LPAs observed four (4) resident rooms in the Memory Care (MC) Unit. Rooms in the memory care unit have no appliances. LPAs observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. The assisted living rooms on the first, second, and third floors are equipped with a refrigerator, microwave, and sink. The assisted living rooms range from studio apartments to two (2) bedroom units. Washer and dryer units are available throughout the floors for resident use, and the commercial laundry area for staff use is in the basement. All rooms were observed to be in compliance. Report Continued on LIC 809-C. RESTROOMS: Restrooms were clean, sanitary, and in operating condition with grab bars and slip-resistant surfaces. Between 10:15AM-11:25AM, hot water temperatures were tested on all floors in assisted living and memory care resident restrooms and were between 95.7-122.4 degrees F, which is not within the required range of 105-120 degrees F. Seven (7) out of ten (10) resident restrooms checked had hot water temperature that was out of compliance. Maintenance technician stated that the water temperatures will be adjusted to be in compliance. KITCHEN: At 10:53AM, the LPAs observed the kitchen to have a sufficient supply of perishable and non-perishable food at the time of the visit. Appliances in the kitchen were clean and appeared functional. Snacks and beverages are available for residents in the Bistro. Food is prepared in the main kitchen, which is located on the second floor. COMMON AREAS: The facility has the following amenities and common areas: office spaces, conference rooms, beauty salon, the bistro, lobby, rooftop access, memory care activity room, dining room, courtyard, and servery kitchen located on the first floor; one (1) theater located on the basement floor; the main kitchen and dining area, activity room, and fitness center located on the second floor; and lounge located on the third floor. Regarding the signal system, the system is activated in the resident bedrooms and restrooms. All systems go directly to a computer at the front desk and to hand-held devices and pagers. Designated staff carry a handheld device, which displays the location of the alarm that has been pulled. Staff also utilize walkie-talkies to communicate with staff accordingly. LPAs observed residents wearing pendants. There are cameras observed in exterior perimeter and entrance. The fire extinguishers are located on every floor in each building and were observed to be fully charged and last serviced on 07/24/2025. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in the hallways. The emergency telephone numbers are posted in the entryway. Other required postings are posted on the first floor. LPAs observed the Ombudsman Poster and DSS Complaint Poster throughout the community. Report Continued on LIC-809C. MEDICATION REVIEW: At 12:52PM, LPA Peraldi, along with Health and Services Director (HSD) Ian Gadea reviewed medications for six (6) residents. Medications are centrally stored and locked in the medication offices. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record (CSMDR) as they were missing start dates. At 01:36PM, LPA observed Resident #1 (R1)’s Diltiazem HCL 120mg tablets had a recorded start date of 11/28/2025 on the medication bubble pack. The medication is thirty (30) tablets with an administration of once a day at bedtime. HSD stated that there was an error in recording the start date as it should have been 12/28/2025, however the CSMDR had no recorded start date. At 02:08PM, LPA observed Resident #2 (R2)’s Vitamin B-12 1000mcg tablets with a recorded start date of 12/22/2025 on the medication bubble pack. The medication is thirty (30) tablets with an administration of once a day in the morning. There were four (4) tablets left, but according to the start date of 12/22/2025, there should be five (5) tablets left. HSD was unable to account for the missing tablet. The CSMDR had no recorded start date for R2’s Vitamin B-12 medication. RECORD REVIEW: Beginning at 01:00PM, LPA Barutyan reviewed five (5) resident and five (5) staff records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, personal rights, and first aid/CPR training. All resident files reviewed were complete and were observed to be in compliance. Two (2) out of two (2) care staff files were missing valid first aid certification by qualified agencies. During today’s visit, LPAs obtained a copy of the facility’s liability insurance. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: Beginning at 02:40PM, LPA Barutyan reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 12/10/2025. The community’s smoke detectors and carbon monoxide detectors are hard-wired and were last tested on 12/09/2025 by Cal Building Systems. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted. Appeal rights and a copy of the report was provided.