Routine inspection (multi-day)·February 27, 2026

Licensing Program Analyst (LPA) Galarza conducted a subsequent unannounced Annual Continuation visit to finish reviewing staff and resident records and issue citations observed during yesterday's visit. Interim Executive Director Anahi Reyes assisted with the visit. The Residential Care for Elderly (RCFE) facility serves residents ages 60 and over. There is a Memory Care Unit for cognitively impaired residents. Infection Control: The facility has an Infection Control Plan and ample PPE supplies. Operational Requirements: The facility has a Dementia plan, a fire clearance for 114 non-ambulatory residents age 60 and above, of which 15 residents may be bedridden, and a hospice waiver for 30 residents. Facility does not handle resident money. 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 6/2/2026. Physical Plant/Environment Safety: The facility is a three (3) story building consisting of 77 resident rooms. The 1st floor consists of a lobby, dining room with outdoor courtyard, kitchen, medication room, administrative offices, electrical room, public restrooms, laundry room, 21 resident rooms, shaded outdoor courtyard area, and a Memory Care unit with multi-purpose room, and outdoor courtyard. The 2nd floor consists of 28 resident rooms, Bistro area, game room, public restrooms, 2 storage rooms, laundry/housekeeping room, outdoor shaded balcony area, and 2 common areas. The 3rd floor consists of 28 resident rooms, fitness room, theater room, lounge, beauty shop, and outdoor shaded balcony area. Delayed egress is in place in the 1st floor Memory Care unit. continuation - Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Twenty eight (28) resident rooms, common areas, and kitchen were inspected. Resident rooms have required furniture, bedding, linens, and lighting. Exit doors are free of any obstruction. The signal system was tested and is operational. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. There are evacuation chairs on 2nd and 3rd floor 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 fire extinguishers. The last fire inspection was conducted by Code Red Fire Inc. The Memory Care Unit tweezers were found in an unlocked dirty refrigerator freezer in the multi-purpose room, as well as unlocked nail polish & nail polish remover in the arts/crafts cabinet. Room 112's ceiling does not have dry wall, and 204 has a hole above the bathtub ceiling. This issue is currently being investigated in complaint control # 28-AS-20260211084916. Rooms 101, 104, 106, 107,110, 111, 112, 113, 202, 211, 311, 320 beds did not have mattress pads. Staffing: A total of 42 staff members provides care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 2/28/2026. Staff have criminal background clearance and training. Nine (9) staff files were requested. Three (3) files were not provided, including the Executive Director/Administrator's file. Staff (S2, S3 & S5) do not have current 1st Aid/CPR training. Staff (S4 & S6's) files did not have health/TB screenings. Resident Records/Incident Reports: 12 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. Five resident files did not have current medical assessments. There were resident files that did not have service plans; however, there is an opened complaint investigation that addresses that issue. RCFE & Ombudsman complaint posters are posted. However, the CCLD RCFE complaint poster posted in the 1st floor hallways does not meet the size 20 x 26 requirement. A technical advisory was issued. Planned Activities: The facility has a posted activity calendar. Sufficient space to accommodate both indoor and outdoor activities was observed in the Memory Care Unit and Assisted Living floors. The facility has a Resident Council. 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. Sanitation practices and kitchen cleanliness was observed. Dining Services Director has a current Food Handling Certificate. Residents have physician orders for modified diets. A diet list was obtained. However, residents (R4 & R8) require a renal diet and they are not receiving renal diet meals. Per Dining Services Director med-tech/nursing staff have not communicated R4 & R8's renal diet needs to the kitchen staff. Incident Medical and Dental: Centrally stored resident medications were reviewed. Missing medications were observed during yesterday's visit. Citation was issued. Medical and dental transportation is provided by family or 3rd party transportation companies. The facility has a non-operable van and no staff driver. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed and is updated. Facility has a First Aid Kit and Manual. Proof of last emergency disaster drill was not provided. Residents with Special Health Needs: There are currently 14 residents receiving hospice services and 15 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 Interim Executive Director Anahi Reyes. A copy of report and appeal rights was issued.