Routine inspection·January 28, 2026

On 1/28/2026 at approximately 9:50 a.m., Licensing Program Analysts (LPAs) Evelin Rios and Lorena Casillas conducted an Annual Required visit. Upon entry LPAs signed in by a security guard at reception. LPAs met with Assistant Administrator Wendi Doyon and explained the reason for the visit. LPAs later met with the Administrator, Edina Lemus. The Inspection Tools was used to complete this visit. LPAs requested a copy of the following: resident roster, personnel report, last fire inspection, menu and activities calendar. At approximately 10:46 a.m., LPA Rios initiated a physical plant tour and the following was observed: By the main entrance and throughout the facility LPA observed appropriate postings such as, resident's rights, Rights of Resident Council, the facility's activity calendar, menu and emergency evacuation routes. Kitchen: The kitchen has an industrial setting and observed to be clean and in proper order. Appliances and fixtures were observed to be functional. Sufficient amount of perishable and non-perishable food was in stock and properly stored. Kitchen is inaccessible to residents. Dishwashing liquids and other cleaning agents are separate from food preparation areas. LPA discussed food delivery, meal planning and overall food monitoring with the Food Manager, A. Sebert. According to the Food Manager the facility hosts a monthly meeting open for residents to discuss future menus. LPA also observed the 72 hour supply of food in the facility and was informed by the Food Manager that another eight (08) day supply of emergency non perishable supply of food is kept in storage by the facility. (Continue to LIC809) (Continued from LIC809) Common Areas : These include the activity room, lounge, snack rooms, laundry rooms and dining areas. The furniture is in good repair. Hallways and passageways are free of obstruction. Surrounding Grounds : Entry/exits and hallways were free of obstruction. There is a courtyard accessible to residents with appropriate outdoor furniture. The outdoor area was free of hazards. There are no bodies of water. Bedrooms: LPA toured five (05) resident bedrooms of which two (02) were private use and three (03) were shared. LPA observed rooms were clean appropriately furnished and had sufficient storage and lighting. Bathrooms: LPA toured five (05) resident bathrooms and found that all bathrooms were clean and equipped with the required grab bars, non-slip flooring, and an adequate supply of toilet paper and hand soap. Medications: At 11:42 a.m., LPA Rios, with the assistance of Licensed Vocational Nurse (LVN) J. Ulmer, conducted a review of medications and medication records at one (1) of the two (2) nursing stations. All centrally stored medications were observed to be securely locked in medication cabinets and properly labeled. Medications requiring refrigeration were stored appropriately in the designated medication refrigerator. With assistance from the LVN, LPA reviewed both the physical medications and the electronic medication records. LPA Casillas reviewed facility's Emergency Disaster Plan (LIC610E), Emergency Operation Plan, Fire and Safety Inspection (STD850) for the modular unit, Fire Drills, Liability Certification and Bond and specialty insurance. LPA Casillas reviewed the annual inspection report conducted by the County of Los Angeles Fire Department. The CA Department of Forestry and Fire Protection conducted an annual inspection on 02/19/2025. Report states that there were no deficiencies noted and that required corrective action previously mentioned have been corrected. LPAs also examined the facility’s infection control plan, fire drill records last conducted on 12/23/25, and after-action reports for both the "Shake Out" drill and the reception of West Los Angeles RCFE residents affected by the Palisades Fire. Facility provided LPAs with a fire system smoke detector inspection conducted by Champions Fire System Inc certifying no defects for devises. It appears all fire extinguishers were last serviced on 01/12/2026. (Continued to LIC809-C) Page 2 of 2 (Continued form LIC8090C) From approximately 1:30 p.m. to 4:32 p.m., LPAs, with the assistance of Supervising Psychiatric Social Worker, S. Misra and Registered Nurse (RN) M. Altamirano, reviewed ten (10) resident records to verify completeness and compliance with licensing standards. Additionally, with the support of C. Ezparza, LPAs reviewed six (6) staff records to ensure adherence to licensing requirements and confirmation of current training. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during today’s visit. Exit interview conducted. Copy of this report issued. (Page 3 of 3)