Routine inspection·April 9, 2026

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. LPA met with Executive Director Sarah Rafael. The Residential Care for Elderly (RCFE) facility serves residents ages 60 and over. There is a Memory Care Unit for cognitively impaired residents. The following were observed/inspected: Infection Control: The Infection Control Plan includes Environmental cleaning and disinfection activities. Operational Requirements: The facility has a hospice waiver for 20 residents. A fire clearance for 100 non-ambulatory residents; of which 10 may be bedridden is in place. Facility handles resident monies and has set up trust accounts. The Surety Bond is current. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 4/11/2027. However, the policy lists the wrong facility name and insured name. Therefore, a technical violation was issued regarding the liability insurance policy. Physical Plant/Environment Safety: The facility is comprised of a 3- story building that has 66 resident rooms, 2 activity rooms, TV room, Namaste room, 3 dining rooms, laundry room, 2 courtyard patio areas, and a Memory Care Unit. The interior and exterior physical plant was inspected. A total of 25 randomly selected resident rooms were inspected. The signal system was tested and is operational; residents use a pendant alert system. Beds have required bedding, linens, and mattress pads. The signal system was tested and is operational. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. Cleaning supplies and toxic substances are inaccessible to residents. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has fire extinguishers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Exit doors are free of any obstruction. There are surveillance cameras in common areas. The last fire inspection was conducted on 3/6/2026 by City of San Gabriel Fire Department. * The 2nd floor ceiling has multiple openings exposing wiring; the ceiling is not painted; wall paper is in disrepair and 3rd floor hallway ceiling has water damage that requires repair and painting. Staffing: A total of 59 staff members provide care and supervision of residents. Personnel Records/Staff Training: Administrator certificate expires 12/15/2026. Staff have criminal background clearance. 10 staff files were reviewed. They contained 1st Aid/CPR training, criminal background clearance, health/TB screenings, 1st Aid/CPR training, and training records. Resident Records/Incident Reports: Eight (8) resident files were reviewed. They contained Admission Agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, and centrally stored medication records. Planned Activities: Facility activity calendar was posted. Sufficient space to accommodate both indoor and outdoor activities was observed. RCFE & Ombudsman complaint posters are posted. Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Kitchen personnel have current food handling certificates. * The 3-door refrigerator temperature is above the maximum temperature requirement, and the food steamer ignition knobs are in disrepair, and as a result the steamer temperature is not able to be regulated. Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family or facility van. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed and is updated. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted in January 2026. Residents with Special Health Needs: There are currently 5 residents receiving hospice services, 9 residents receive home health services, and no residents have prohibited health conditions. Individual Service Plans, Appraisals, and postural support physician orders are on file. Pursuant to Title 22, deficiencies were observed and are cited. Exit interview was conducted with Sarah Rafael. A copy of report and appeal rights were issued.