Routine inspection (multi-day)·October 2, 2025

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 9:28AM to conduct an Annual Continuation visit. The LPA met with the Executive Director (ED) Dion Gallarza and explained the reason for the visit. Entrance interview conducted. At 9:31AM, the LPA and ED conducted a brief health and safety tour of the physical plants areas, and no immediate concerns were observed. RECORDS: Resident records were reviewed at 9:57AM. LPA Huynh reviewed ten (10) files for, but not limited to: admissions agreements, medical assessment, appraisals, and consent forms. Resident records reviewed were in order at this time. The LPA reviewed eleven (11) personnel records for, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification, and appropriate trainings. Staff files reviewed were in compliance with regulation at this time. Three (3) staff did not have a certified first aid/CPR training on file, however, received Relias online module trainings and certified staff are on the premises at all times. The LPA advised the ED to ensure direct care staff receive first aid/CPR certification. Report Continued on LIC 809-C INFECTION CONTROL/EMERGENCY DISASTER: The LPA reviewed the facility's Infection Control Plan and Emergency Disaster Plan. LPA noted that the facility is in compliance with regulation with both plans reviewed annually. The facility conducts emergency disaster drills monthly, with the last drill documented on 09/16/2025. Fire alarm system is tested annually with the last inspection on 05/01/2025. Additionally, the commercial kitchen was inspected on 08/30/2025 and fire doors were tested on 09/23/2025 by GFP Guard Fire Protection Services Inc. MEDICATION: Medication review began at 11:30AM. The LPA reviewed medications for five (5) residents. Medications were maintained locked inaccessible to residents in the Medication Room located on the first floor in the Memory Care Unit. Resident medications reviewed were documented and stored in compliance with regulation at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.