Routine inspection·January 29, 2026

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual visit. LPA was greeted by staff and the purpose of the visit was explained. Executive Director Michele Johnson and Maintenance Director Rene Sandoval assisted with the tour. The facility is licensed to serve age range 60 and over, 148 non-ambulatory of which six (6) may be bedridden. Bedridden is approved for all first and second floors. The facility has a hospice waiver for 10. Approved for delayed egress. The facility is a two-story building located in a residential area of Glendora operating as an RCFE with a Memory Support unit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Operational Requirements: Facility is operating within the limitations of their license. They have 10 residents under hospice and 1 bedridden resident. LPA observed current liability insurance. Physical Plant/Environmental Safety: During facility's tour, LPA observed all common areas in good repair. Carbon monoxide and smoke detectors are located in every resident room. A total of 8 residents' rooms for assisted living, and memory support were selected at random for inspection. Each room contained the required furnishing, with sufficient lighting, and bedding supplies. Linens were observed to be clean and in good repair. continued on LIC809C Water temperature was tested in each resident bathroom and measured between 113°F - 122 ° F, which is not within the required 105-120 degrees F. Bathrooms were observed with grab bars and non-slip mats or flooring. Disinfectants, cleaning solutions, and sharps are locked and not left unattended. Passageways, hallways, stairways are clear of debris and obstructions. Auditory signal/pendant buttons were tested for 3 residents and staff responded less than 4 minutes. Facility has a fire sprinkler system throughout. Fire extinguishers were observed throughout the facility. Delay egress exit doors were tested and in working condition. Elevators were observed working. There are no pools or large bodies of water. Resident Rights/Information: License, Let us Know (PUB 475), Ombudsman, and personal rights posters were posted in the hallway. Food Services: LPA toured the commercial kitchen and observed good quality/commercial food supplies for at least 2 days of perishables and 7 days of non-perishables. Kitchen was observed clean and free of pest. Cleaning supplies were observed stored away from food supplies. Staff were observed practicing hygiene and infection prevention. A list for residents with modified diets was observed. Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in medication carts in each medication room. LPA reviewed medication for 5 residents. Facility uses EMAR and medications are dispensed as prescribed. Resident Records/Incident Reports: LPA reviewed 8 residents files. Files were available electronically and each contained admission agreement, medical assessment, TB clearance, a current needs and care appraisal, pre-appraisal. Disaster Preparedness: LPA obtained a copy of and reviewed emergency disaster plan LIC 610E. Evacuation chairs were observed in staircase. Emergency drills are conducted quarterly; last emergency drill was conducted on 01/22/2026. continued on LIC 809C page 3 Staffing: Administrator certificate was reviewed for Michele Johnson. Documents were submitted in 2023 to licensing for change of Administrator. During today's visit, LPA received documents to review for the change of Administrator. CPR/First aid training was observed for staff. Personnel Records/Staff Training: LPA reviewed 8 staff files. Files included; TB clearance, health screening, background clearance, personnel record, and training. Planned Activities: Facility has an Lifestyle Director to coordinate activities provided at the facility. LPAs observed various rooms throughout the facility with puzzles, reading areas, music, crafts, activities and movies. Residents with Special Health Needs: Facility is serving 1 bedridden resident and 11 residents on hospice. Memory Support unit residents do not have access to knives/sharps, chemicals or medications, unless the physician allows them to have access to any. A delay egress system was observed and tested in the Memory Support unit. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were cited during today’s visit. Exit interview was conducted with Michele Johnson and a copy of this report was provided.