Routine inspection·May 16, 2025

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Rita Pena and Jeene De Castro and explained the purpose for today’s visit. The facility is licensed to serve 150 Non-Ambulatory residents ages 60 years and above. Facility has a Dementia Special Program with Delayed Egress System and an approved Hospice waiver for 27 residents. Facility currently has 20 residents under hospice care. The Facility is a single story building located in Downey, CA. A tour of the facility included: main entrance/lobby, Administrator Office, Administrative Assistant Office, this is a locked facility that requires code to access inside, there are 75 resident bedrooms with private bath, 2 activity rooms, 2 changing rooms, 1 shower room, beauty shop, craft room/staff training room, staff lounge, 2 storage rooms, oxygen tank closet, Medication Room, Doctors Office, 1 large dining room, 1 small dining room, kitchen, linen room, laundry room, 2 visitor restrooms and an outdoor patio area that is enclosed within facility. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility has sufficient PPE supplies and the required Infection Control Plan on file. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Dementia Plan and training, and facility maintains the required liability insurance, expires 7/2025. Staffing : There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. (Continued on LIC809-C) Physical Plant & Environment Safety: LPA toured facility, a total of 9 residents’ bedrooms were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems located in each bathroom and near their bed that were tested and operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility resident private bathrooms and measured within the required range of 105-120 degrees. There is a large shaded patio area for residents. Personnel Records-Training : Staff have criminal record clearance, current First-Aid training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 7 staff files with no issues observed. Administrator Marie "Jeene" De Castro certificate expires on 6/10/25, has already begun the renewal process. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 8 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conducts/evaluate planned activities. There is sufficient space both indoor and outdoor for activities. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored and are in their original containers. LPA reviewed 10 residents medications with no issues. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 5/8/25. Residents with Special Health Needs: Facility admits residents with dementia and hospice, staff files reviewed today all have required training documented. Residents under hospice care had the required documentation on file. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held, a copy of the report was provided.