Inspector’s narrative
What the inspector wrote
Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Annual Continuation – Case Management visit today. LPA, met with Kay Cano, Executive Director, and the reason for the visit was explained. The facility is licensed to serve 245 non-ambulatory residents ages 60 and over, of which 30 may be bedridden on 1st and 2nd floors, there is an approved delayed egress and Hospice waiver for 35. There are currently 26 residents on hospice. Kay Cano and John Arbona, Maintenance Director, facilitate today’s visit which focused on inspecting the physical plant.
The facility is an 8-story building located in Pasadena. A tour of the facility included:
*The 1st floor:
Large dining room, kitchen, salon, theater, fitness room, linen room, laundry room, trash room, club/TV room, billiard room, staff office, multipurpose area, family living room area, an elevator, two gender specific public restrooms and 20 shared resident rooms with bathrooms.
*The 2nd floor:
Lobby area ,24 resident rooms with bathrooms laundry room, employee break room, medication room, lobby, and staff office.
*The 3rd floor:
Houses the Memory Care unit, 12 shared and 16 private resident rooms, two dining rooms, activity room, staff laundry room, game room, room and activity alcove. The unit has Egress alarms on three doors exiting the floor to the stairwell.
*The 4
th
floor:
Game room and alcove, staff studio, laundry room and 29 resident rooms with bathrooms.
***Continues on LIC 809-C****
*The 5th floor:
Casino-style room, laundry room, and 30 resident rooms with bathrooms.
^The 6th floor:
Computer alcove, laundry room and 30 resident rooms with bathrooms.
*The 7
th
floor:
Library, laundry room and 30 resident rooms with bathrooms.
The 8th floor:
Laundry room, quiet/resting spots and 30 resident rooms with bathrooms.
The following was observed during today’s inspection:
The facility was observed clean inside and out. Walkways, passages, exits, ramps, hallways and staircases were observed free of debris and obstruction. Furniture in the common areas is kept in good repair. During today’s visit, 23 resident rooms were inspected. Rooms were observed to have the required furniture and bedding. Water temperature was tested in resident bathrooms and measured between 106.3-119.4 degrees F which is within compliance range. Each resident room has a call button in the bedroom and a pull cord in the bathroom. Call buttons and pull cords were observed operational. Each resident room has individual smoke detectors which were tested and working properly. The dining rooms were inspected and were found to be clean, and sufficient seating is available for residents. The kitchen was inspected, and food preparation areas, stoves, refrigerators and freezers are kept clean and maintain adequate temperatures. The facility has sufficient 2-day perishable and 7-day non-perishable supply of food. Food is kept properly stored and within expiration limits. Cooking utensil room and dry/canned food pantry were inspected; however, rodent droppings were observed underneath the shelfing units in the corners by the walls. The outdoor environment has a covered seating area, walking path and sport areas and a resident garden.
Fire extinguishers were observed throughout the building on every floor. Fire extinguishers were observed charged and readily available for use. Facility staff conduct safety drills monthly and last drill was conducted on 12/16/25. Facility’s fire alarm and sprinkler system are inspected annually, and the last inspection was completed on 5/19/25. Pasadena Fire Department inspected the facility for Fire and Life safety on 6/16/25 and no violations were noted, according to records reviewed today. Evacuation chairs were observed on each staircase and are kept in good repair. The 6
th
floor houses the facility’s incontinence care and PPE supplies. The kitchen houses an emergency supply of food and water.
***Continues on LIC 809-C page 2***
The facility has three vehicles which are used for resident transportation to appointments and outings. Keys for vehicles are kept in the main office. Reviews of records indicate that vehicle maintenance and repairs are being conducted regularly. Vehicle insurance and registrations are kept up to date.
During today’s visit, LPA interviewed 16 residents and three staff. A deficiency was noted and citation issued. Exit interview was conducted with Kay Cano, Executive Director, and a copy of this report, 809-D and Appeal Rights was provided.
