Routine inspection·February 10, 2026

Licensing Program Analyst (LPA) Vaid conducted an unannounced annual inspection visit. LPA met with Director of Nursing Suzana Zadourian. Nursing director assisted LPA with the visit and facility tour. Administrator, Pamela Parsons, arrived shortly after and assisted with the facility tour. The facility is licensed and has Fire clearance approval to serve for a capacity of 175 non- ambulatory residents including 25 bedridden residents, ages 60 and above. The facility has an approved Hospice Waiver on file for twenty-three (23) residents. Eighteen (18) residents currently on Hospice. Facility has an approved Dementia Care Plan in their plan of operation and accept residents with dementia. Facility does not handle residents’ monies. During the visit, a tour of the facility, review records and interviews with staff and residents’ consisted of the following: 1. Infection Control: Infection control practices were observed. Infection control plan is on file. 2. Physical Plant/Environment Safety: The facility is in a residential neighborhood, consists of three floors and has 189 resident bedrooms and 189 resident bathrooms. Level 1 has resident bedrooms, memory care unit, recreation/activity rooms, beauty shop, storage rooms, employee lounge, library, and laundry rooms. 2nd level is memory care, reception/lounge area, resident bedrooms, dining room, kitchen, multiple offices, recreation/activity rooms and laundry rooms. 3rd level consists of resident bedrooms, nurse's office, medication room, penthouse, recreation/activity rooms and laundry rooms. CONTINUED ON 809C.................. A physical tour was conducted. LPA randomly toured resident rooms on each floor in building sections A, B, C, D, E and F. Residents’ rooms were well furnished and in compliance. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 105.0 – 120.0 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. The resident rooms are equipped with a signal system located in each restroom and facility phones to call the front desk. Facility had central air and heating accommodations in the common areas. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits are operable at the memory care unit at the lower level. Interior and exterior space is available to permit residents to walk in safe and comfortable environments. 3. Operational Requirements: The Program Design was reviewed. Fire clearance approved for 175 non- ambulatory residents, 25 bedridden residents, ages 60 and over. Floor of bldg. F & second floor of bldg. F cleared for dementia wings/ with delayed egress. Each dementia unit consisting of 11 rooms. May retain twenty-three (23) Hospice residents. Eighteen (18) residents currently on Hospice. Care and supervision to meet the residents’ needs was observed. Liability insurance expires 02/28/2026. 4. Staffing: One hundred and two (102) full-time staff and twenty nine (29) part-time staff members provide care and supervision to the residents. 5. Personnel Records/Staff Training: Five (5) staff files were reviewed for criminal background clearance and training. All Five (5) staff records reviewed have a health screening with a Tuberculosis clearance, and five (5) staff have First Aid/CPR training that are active. Administrator certificate is current and expires on 07/31/2026. 6. Incident Medical and Dental: All residents have an Appraisal/Needs and Services Plan on file. Staff training was on file. CONTINUED ON 809C...................... 7. Resident Rights/Information : Physician orders were reviewed for five six (6) resident files. Medications were also reviewed for six (6) residents. Medications are centrally stored and locked in the nurse's office on the third floor. First aid kit is fully stocked. Mandated documents and signages are posted in common areas. Resident records are stored in a locked cabinet and inaccessible to residents. 8. Resident Records/Incident Reports: Six (6) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Resident records are stored in a locked cabinet and inaccessible to residents. 9. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Staff is adhering to residents' meal plans as per physicians orders for mechanical/ diabetic diets Sufficient food supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Food is stored in covered containers at the appropriate temperatures. Pesticides or poisons are not stored in the food areas, stored in separate closet inaccessible to residents. Freezer and refrigerator has required temperatures, which was within Title 22 Regulation guidelines. 10. Disaster Preparedness: Emergency and Disaster Plan (LIC610E) was found in the facility. The last Fire/Emergency Drill are conducted quarterly on by third-party company on 11/08/25 PM and NOC shift. 11/10/2025 AM shift safety drills were conducted. Smoke and carbon monoxide detectors are operable and in compliance. Fire extinguishers were last serviced on 02/06/26 are fully charged and in compliance. 11. Planned Activities: Sufficient Space is provided to accommodate both indoor and outdoor activities. Sufficient equipment and supplies are provided to meet the requirements of the activity program. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. Outside grounds were toured and pool/spa area with self-latching fenced gate was observed. The outdoor activity area has a shaded patio with ample seating. 12. Residents with Special Health Care Needs: Eighteen (18) residents are receiving hospice services. There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview was held with Administrator and a copy of annual facility inspection report was provided.