Routine inspection·April 8, 2025

On 04/08/25, 9:00 am Licensing Program Analysts (LPAs) Nadia Shahbazian and Evelin Rios conducted an unannounced required annual inspection. LPAs met with Executive Director, Silvia Valdez and explained the reason for the visit. Facility is licensed as a two-story building. Fire clearance approved for one hundred (100) non-ambulatory residents; ten (10) of whom may be bedridden. Hospice waiver is approved for thirty (30) residents. LPAs requested copies of the resident roster, Personnel Report (LIC 500), nine (9) randomly selected resident records and seven (7) staff files. At approximately 10:00 am, LPAs reviewed seven (7) randomly selected staff files for completeness, LPAs observed the files to be complete with updated training records. From 12:00 pm to 1:20 pm, LPAs along with the Executive Director conducted a tour of the physical plant. During the tour, LPAs interviewed six (6) residents and four (4) staff. During the physical plant tour LPAs observed the following: The Screening/Reception area is located immediately upon entrance. Required postings were displayed at the reception area. Facility’s main door is the primary entry/exit access. The facility has five (5) delayed egress exit doors. LPA tested one of the delayed egress doors on the first floor and observed it to function properly. Facility has one elevator. LPAs observed an evacuation chair atop of one (1) of the three (3) stairwells. Common areas: First floor has a dining room, lobby/television room, outside and an inside patio areas. Second floor has an activity room. Common areas observed to be clean and furnishings observed to be in good condition. No obstructions or hazards were observed. Carbon monoxide detectors were observed on the first floor and were functional. Fire extinguishers are located all throughout the facility and last inspected on 04/01/2025. The facility is equipped with cameras in common areas and a sprinkler system. Kitchen: Facility’s kitchen was observed to be clean, sanitary, and inaccessible to residents. LPAs observed an adequate supply of perishable foods for two (2) days, and non-perishable food supply for seven (7) days, which were located in the refrigerator, freezer, and pantry. Food was properly labeled and stored. Emergency food is stored in a separate walk-in pantry. Sharps are stored in the kitchen; inaccessible to residents. LPAs observed records of special dietary needs and weekly menu in the kitchen. Medications were kept in locked medication carts in the medication room, inaccessible to residents. LPA observed complete first aid kits and first aid manual in the medication room. At 1:25 p.m., medications and medication records for ten (10) residents were reviewed by LPA Shahbazian with the assistance of the Regional Director, Lisa Pham. Facility Disaster drill was last conducted on 03/25/2025. Fire protection equipment were last inspected by Delta Fire Equipment, INC on 05/13/2024. Review of records indicate facility passed the annual fire inspection. LPA Rios reviewed the facility's liability insurance, infection control plan, and disaster plan. Records were complete and up-to-date. Due to time constraints, LPAs were unable to complete today's annual inspection. LPAs will complete the inspection at a later date. Exit interview conducted. Copy of report provided to Executive Director.