Routine inspection·August 28, 2025

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Hector Vargas, Administrator and explained the purpose of the visit. Facility is licensed for 40 residents age range 60 and over, of which 30 ambulatory and 10 non-ambulatory; approved hospice waiver for (5) hospice residents. There are currently (34) residents, 60 years and older residing in the facility, (0) bedridden and (0) hospice residents. Residents residing in the facility receive case management services provided by San Gabriel Pomona Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has a updated Infection Control Plan in place. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan was completed and up to date. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Facility does not accept or retain residents with dementia. LPA reviewed the Liability Insurance that is in place. LPA reviewed the Surety bond that is in place. Fire and Earthquake drill was last conducted on 07/09/2025. Physical Plant/Environment Safety: The facility is a single-story building located in a commercial area. The facility consists of (2) separate buildings: the 1st building (single story) consists of (20) resident rooms and (14) bathrooms, (5) community shower rooms. Outside patio, Medication room, Laundry room, Living room, Dining area, Kitchen and Pantry. Physical Plant/Environment Safety [Cont.]: The 2nd building (2 story) consists of Administrative office, Medical Office, Storage room, Detached garage, Conference room and Accounting Office (upstairs). The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. LPA inspected five (5) residents' rooms and each resident bedroom has the required furniture such as the bed, bed frames, nightstand, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. The bathrooms were observed to be clean and operational. Each resident rooms had a bathroom that included a water basin and toilet. Cleaning supplies and toxic substances are inaccessible to residents. The LPA along with the Administrator toured and tested hot water temperature in five (5) random resident rooms (Rooms #5, # 9, 11, 12, 19 and shared shower room). Water temperature readings measured between 105.0 degrees F and 111.3 degrees F within the required 105 - 120 degrees Fahrenheit. LPA measured the Shared Shower room hot water temperature at 110.3 degrees F which is within the required 105 – 120 degrees F. Sharps are kept locked and inaccessible from residents. Cleaning supplies are kept locked and inaccessible from residents. There are cameras without audio in the common areas. Carbon Monoxide detectors were tested and working properly. Fire extinguishers were observed throughout the facility and were last serviced on 04/15/2025. Smoke detectors, fire sprinklers and pull fire alarm system observed and hard wired to the City of Sierra Madre Fire Department. Staffing: There are sufficient staff to provide care and supervision to the residents, including the Administrator. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility. Personnel Records-Training: LPA reviewed five (5) staff files includes: Personnel Record, Health clearance, TB Result, Criminal Background Clearance, Employee Rights, 1st Aid/CPR training are current. Administrator's certificate expires on 06/23/2026. Resident Rights-Information: Resident personal rights, complaint hotline information and visitors’ policy posters are posted. Per Administrator, facility provides internet services to all residents and have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. Outdoor has a shaded area for activity purposes. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted. The facility has a Resident Council and council members/residents meet on a monthly basis. Food Service: Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. There are five (5) residents that have a modified diet. Sufficient food supply is stored in the kitchen and pantry area consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Pesticides and cleaning supplies are kept away from the food preparation areas. Incident Medical and Dental: Medications were reviewed for (5) residents to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are centrally stored and in their original containers. Medications are administered as prescribed by the Physician. Medications are bubbled packed. The first aid kit was observed and has all required items. Resident Records/Incident Reports: LPA reviewed five (5) resident files that include: the Face Sheet, Admission Agreements, Physician's Reports, Ambulatory Status, TB Clearance, Individual Program Plan (IPP), and Personal Rights. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: Three (3) residents are receiving home health services. There are three (2) residents with a Restricted Health Condition and the LPA reviewed the current Restricted Care Plans in file. There are no residents with prohibited health conditions. Per the California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during today’s visit. Exit interview was held and a copy of the report was provided to Hector Vargas, Administrator.