Inspector’s narrative
What the inspector wrote
Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced annual inspection visit. LPA met with the Administrator, Claudia Sanchez and the purpose of the visit was explained. The facility serves elderly residents ages 60 and older. A hospice and Dementia waiver is in place.
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 an updated Infection Control Plan in place.
Operational Requirements:
A hospice waiver for 15 residents has been approved. A fire clearance for 48 ambulatory, 32 non-ambulatory, of which 7 may be bedridden is in place. A hospice and Dementia waiver is in place. LPA observed the valid Surety Bond in place. LPA observed the Valid Liability Insurance in place. Fire and disaster drills were last conducted on 04/22/2026.
Physical Plant/Environment Safety:
The facility consists of 48 resident rooms in a two-story main building and two (2) detached buildings, activity room, dining room, laundry area, two (2) courtyard patio areas, and one 2nd floor balcony. 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. Cleaning supplies and toxic substances are inaccessible to residents. The fireplace is closed and inaccessible to residents. The facility has fully charged fire extinguishers that were last inspected on 11/14/2025. The Carbon Monoxide Detectors were tested and is operational.
[Continue to LIC809-C]
Physical Plant/Environment Safety [Cont.]:
LPA inspected eight (8) residents' rooms and each resident bedroom has the required furniture such as the b
ed, bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. The outdoor area has a shaded area for activity purposes. Resident beds have the required linen, and the linen is in good condition. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, skid mat/strips and shower chair. LPA tested hot water temperature in eight (8) random resident rooms (Rooms: 6, 8, 10, 12, 14, 17, 26, and 32) in the 1
st
and 2
nd
floors. Water temperature readings measured between 105.2 degrees F - 127.7 degrees F, which is not within the required temperature 105 to 120 degrees F. Stairwell evacuation chairs were observed.
Staffing:
There are sufficient staff members to provide care and supervision to the residents. 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/Staff Training:
LPA reviewed
six (6) staff files which include: Personnel Record, health screening, TB test results, Employee Rights, valid First Aid/CPR/AED Training, ongoing staff and Dementia training. The administrator’s certificate is valid and expires on 04/25/2028.
Resident Rights-Information:
Resident personal rights, complaint hotline information and visitors’ policy posters are posted in the 1st floor. Facility provides internet services to all residents and they have access to the facility phone.
Planned Activities:
Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted.
Food Service:
Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept clean and stored properly. Sufficient food supply is stored in the kitchen and pantry areas consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Per Administrator, there are Four (4) residents on modified diets. Physician orders are on file and special diet lists are kept in the kitchen area.
[Continue to LIC809-C]
Incident Medical and Dental:
LPA reviewed
five (5) centrally stored resident medications which contain a 30-day supply of medications. Medical and dental transportation is provided. Based on Record Review, LPA observed and confirmed with the Administrator that Resident #1 (R1) is missing the following medications: Atorvastatin, Aripiprazole, Levofloxacin, Ferrous Sulfate, Ciclopirox, Ammonium Lactate, Selenium Sulfide, Nystatin, and Diclofenac Sodium. Based on Record Review, LPA observed that per Resident #2 (R2’s) physician’s report dated 2/6/2026, R2 is unable to administer their own medications and unable to administer their own injections. R2 requires injections for diabetes. Additionally, per Administrator interview, the facility has no skilled medical professional to administer injections.
Resident Records/Incident Reports:
LPA reviewed five (5) resident files that include the face sheet, Identification and Emergency Information Form, Admission Agreements, Physician's Reports, Ambulatory Status, TB clearance, Physician's Orders, Preplacement Appraisal, Resident Appraisal, and Personal Rights.
Disaster Preparedness:
The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. Facility maintains documentation of the required emergency drills. The facility has a First Aid Kit with all required items.
Residents with Special Health Needs:
Per Administrator, there are two (2) residents that receive hospice services and five (5) resident receives home health services. Per Administrator, there are 14 residents have a Dementia diagnosis and are located in the 1st floor. Postural support physician orders are on file. Full bed rails for mobility assistance were observed in some resident rooms and LPA reviewed resident files with bed rail orders. No residents have prohibited health conditions.
$ 250.00 Civil Penalty is being issued during today's visit as a result of a repeat violation within a 12-month period ( 87303(e)(2) ). LIC421FC provided to the Administrator during today's visit.
Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the Administrator, Claudia Sanchez.
