Routine inspection·March 19, 2026

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit. LPA met with Executive Director Pam Ogot and LPA explained the purpose of the visit. Executive Director helped assist the LPA with the inspection. Facility is licensed for 45 non-ambulatory, maximum of (8) hospice residents and (4) bedridden residents ages 60 and over. Currently, there are (40) residents in the facility who are 60 years and older, of which no residents are bedridden and two (2) are receiving hospice care. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has an Infection Control Plan. Staff are adhering to infection control requirements. Emergency and disaster plan was completed and up to date. Infection control practices and Personal Protective Equipment (PPEs) were maintained. Operational Requirements: The Infection Control Plan has been added to the Plan. Facility accepts and retains residents with dementia. Approved Dementia Care Plan is in their plan of operation. There is no separate memory care unit inside the facility. Facility is approved for (8) hospice residents. Liability Insurance is in place. Surety bond is in place. Fire drill was last conducted on 02/20/2026. Disaster drill was last conducted on 02/20/2026. Physical Plant/Environment Safety: LPA along with Executive Director toured the facility. The facility is a 2-story building located in a residential community. The grounds in the facility are well landscaped and have a leveled walkway to the entrance of the building. The facility consists of: First floor: Lobby, Administrative offices, Physical Plant/Environment Safety [Cont.]: Medication room, Laundry room, (1) Elevator, Large Dining area, Kitchen, Pantry, Activity room/patio, Storage room, Patio by the main entrance, and resident rooms. Second floor: Resident bedrooms, Beauty shop, Activity room and a community shower. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility is equipped with cameras in the common areas. LPA toured random rooms and observed each bedroom to contain the required furniture and linens. Extra linens and towels are in the storage room Each residents' room has their own restroom. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in six (6) random resident rooms (Rooms #1, #7, #9, #207, #211, #215) in the first & second floors and the water temperature readings were from 109.5 degrees F to 113.5 degrees F which were within the required 105 - 120 degrees Fahrenheit. LPA observed call signals in six (6) random resident rooms and were working properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operational and compliant. Two (2) Carbon Monoxide detectors were tested and are operable. LPA observed five (5) fire extinguishers throughout the facility and are fully charged and last inspected on 01/29/2026. Pull Fire alarm system observed and connected to the City of Monrovia Fire Department. Delayed egress devices are in place. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Staffing: A total of (34) staff members provide care and supervision to the residents, including the Executive Director. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility. Personnel Records-Training: LPA reviewed six (6) staff files which include Job Application, health screening, TB clearance, medication management training, Employee Rights, food handling certificates, and 1st Aid/CPR/AED training. Executive Director's Administrator’s Certificate expires on 09/15/2026. Resident Rights-Information: Resident personal rights, complaint hotline information and visitors policy posters are posted in the lobby by the main entrance. The facility provides internet service to all residents and have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted in the hallway. The facility has a Resident Council and council members/residents meet on a monthly basis. Food Service: Sufficient food supply is stored in the kitchen and pantry area consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. Per Executive Director, there are no residents with a modified diet. LPA observed unlabeled food containers in the freezer and refrigerator. Incident Medical and Dental: Medications are centrally stored and properly labeled in their original containers or bubble packs. First aid kits are maintained in the medication room and in the front office. LPA reviewed five (5) residents medications in the medication room with no issues observed. Medical and dental transportation is provided. Resident Records/Incident Reports: LPA reviewed five (5) resident files that include Identification and Emergency Information Form, Admission Agreements, Physician's Reports, Pre-Placement Appraisal, TB clearance, Ambulatory Status, Functional Capability Assessment, Physician's Orders, Personal Rights, Appraisal Needs and Services Plan. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Facility provides training on staff's responsibilities during an emergency or disaster. Residents with Special Health Needs: Per Executive Director, (38) residents are receiving home health services, two (2) residents are under hospice care and no residents are bedridden. Facility admits residents with dementia and staff files reviewed today all have required training documented. LPA observed half bed rails for mobility assistance in some resident beds. Physician orders for bed rails are in file. There are no residents with prohibited health conditions. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during today’s visit. Exit interview was held and a copy of the report was provided to the Executive Director, Pamela Ogot.