Routine inspection·June 9, 2025

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 9:08AM for a required one year visit. The LPA met with Administrator Amber Leigh and explained the reason for the visit. Entrance interview conducted. At 9:34AM, the LPA and Administrator 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 facility is a two-story building. The following was observed: COMMON AREAS: Located on the first floor is the lobby, dining room, activity room, office, and kitchen that is attached to the Skilled Nursing Facility side of the building. Located on the second floor is the activity room and medication room. The LPA observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. There were cameras in the common areas. Required postings were found in the hallway on the first floor by the office. There are fire extinguishers throughout the facility, which were serviced 05/02/2025. Emergency food and water is stored in a locked closet located on the first floor. There is one outdoor patio located on the first floor by the lobby which is utilized as a smoking area. The LPA observed a grill and outdoor furniture, with a covered shaded area for residents. There were no bodies of water observed during today’s visit. Report Continued on LIC 809-C RESIDENT ROOMS: The LPA observed ten (10) randomly selected rooms on the first and second floor and no immediate health or safety hazards were observed. Restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Appropriate furniture was also observed in the units. Water temperature was tested throughout the units and measured between 96.3 degrees F and 107.1 degrees F, which is not within the required range of 105 degrees F and 120 degrees F. KITCHEN: The kitchen is located on the 1st floor in the Skilled Nursing Facility. The kitchen was observed to be in compliance with Title 22 regulations. Food deliveries occur every Tuesday and Friday. There was a sufficient supply of perishable and non-perishable food. Food appeared to be of good quality. Administrator stated the residents’ meals are carted in from the kitchen to the dining room/resident rooms. RECORDS: Records were reviewed at 10:25AM. The LPA reviewed ten (10) files for, but not limited to: admissions agreements, medical assessment, appraisals, and consent forms. LPA observed one (1) out of ten (10) resident records did not have a TB test on file. Administrator stated the resident is currently in the Skilled Nursing Facility and will have a TB test completed while they are there. The LPA reviewed six (6) personnel records for, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, and first aid/CPR certification. LPA observed one (1) staff having a 1 st Aid/CPR training which expired in 10/2023. INFECTION CONTROL/EMERGENCY DISASTER: LPA reviewed the facility's infection control plan and Emergency Disaster plan. LPA noted that the facility is in compliance with regulation. Facility conducts emergency disaster drills as required with drills conducted monthly, with the last drill documented on 05/06/2025. The fire alarm system is tested annually with the last inspection on 03/28/2025 by the Los Angeles Fire Department. Report Continued on LIC 809-C MEDICATION: Medications review began at 1:57PM. The LPA reviewed medications for five (5) residents. Medications are maintained locked and inaccessible to residents in the medication room located on the second floor. Five (5) out of five (5) resident medications reviewed were documented and stored in compliance with regulation at this time. Five residents and four staff were interviewed. No complaints noted. Documents obtained: LIC 500 Personnel Roster. Pursuant to CA Title 22 Regulations, the following deficiencies were cited (Refer to LIC 809-D). Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.