Routine inspection·September 5, 2025

Licensing Program Analysts (LPAs) Galarza and Gabriela Castro conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to Executive Director Subishsani Kumar. The Residential Care For Elderly (RCFE) facility serves cognitively impaired residents ages 60 and over. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed. The facility has sufficient supply of Personal Protective Equipment (PPEs). Operational Requirements: The facility has a hospice waiver for 20 residents. All bedrooms are approved for non-ambulatory residents. Facility does not handle resident monies. 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 2/1/2026. The facility entire facility serves residents with Dementia. Physical Plant/Environment Safety: Facility is a 2-story building consisting of 43 resident rooms, 2 activity rooms, outdoor courtyard, 2 dining rooms, side patio in 1st floor, 2nd floor terrace patio, conference room, lobby room, kitchen, employee lounge, and office.The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There is a water fountain located in the 1st floor. Cleaning supplies and toxic substances are inaccessible to residents. Most beds had required bedding, linens, and mattress pads with the exception of 10 beds. The signal system was tested and is operational. Water temperature readings did not measure within tthe required 105 - 120 degrees Fahrenheit. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has charged fire extinguishers. The last fire inspection was conducted on 3/13/25 by State of CA Fire Marshall. Rooms 110, 115, and 210 had oxygen tanks in the rooms but no signs of "No Smoking-Oxygen in Use". Staffing: A total of 37 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 12/27/2025.. 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. Administrator on record is not current. A citation was issued. Resident Records/Incident Reports: 10 resident files were reviewed. They contained admission agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Centrally stored medication records were reviewed. R6's medical assessment is dated 7/28/23; a citation was issued. RCFE & Ombudsman complaint posters are posted near the main entrance. A technical advisory was issued pertaining to the size of the RCFE poster. Planned Activities: Facility activity calendar was posted. Sufficient space to accommodate both indoor and outdoor activities was observed. 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. 18 residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Director of Culinary Services F ood Handling Certificate is current. 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. R1 & R2 were missing medications. A citation was issued. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 9/3/2025. Residents with Special Health Needs: There are currently 16 residents receiving hospice services, 2 receive home health services, and no residents have prohibited health conditions. Individual Service Plans and Appraisals are on file. Postural support physician orders are on file. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview, copy of report/appeal rights was conducted with Executive Director Subishsani Kumar.