Routine inspection·October 6, 2025

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to Business Office Manager Michelle Castillo. The Residential Care for Elderly (RCFE) facility serves residents ages 60 and over. There is a Memory Care Unit for cognitively impaired residents. 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 an approved fire clearance for 104 ambulatory and 116 non-ambulatory residents, of which 104 residents may be bedridden. A hospice waiver for 25 residents is approved. 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. Physical Plant/Environment Safety: The facility is a 2-story building consisting of 119 resident rooms, Memory Care Unit, 2 activity rooms with fireplaces, library, game room, beauty salon, private dining room, dining room, shower rooms on the 1 st and 2 nd floors, outdoor courtyards with shaded areas, employee lounge, and offices. Resident rooms have required furniture, bedding, linens, and lighting. The majority of the resident rooms inspected had beds without mattress pads. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. Cleaning supplies and toxic substances are inaccessible to residents. The signal system was tested and is operational. Water temperature readings measured within the 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. Rooms 130 & 133 do not have No Smoking/Oxygen-In Use signs. The Memory Care Unit had cleanliness issues and deferred maintenance. The last fire inspection was conducted on 4/30/25 by Pasadena Fire Department. Staffing: A total of 90 staff members provides care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 1/25/26. 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. Staff (S3, S5, S7, S8) do not have 1st/Aid CPR cards on file and/or had expired cards. 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, and centrally stored medication records. RCFE & Ombudsman complaint posters are posted. A technical advisory was issued due to size requirements. Planned Activities: Facility activity calendar was posted in the. 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. Residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Executive Chef has a current Food Handling Certificate. 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. Four of R1's medications have not been filled. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed and is updated. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 8/8/25. Residents with Special Health Needs: There are currently 12 residents receiving hospice services, 59 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 California Code of Regulations, Title 22, deficiencies were cited. Exit interview, copy of report/appeal rights was conducted with Michelle Castillo.