Routine inspection·February 9, 2026

Licensing Program Analyst (LPA) Elena Mallett conducted an unannounced annual inspection of the facility. LPA arrived and met with staff in charge, Gloria. The purpose of today’s visit was explained. Administrator Shelly Yamishiro joined the visit shortly after and stayed for twenty minutes and then had to leave on personal business.Administrator returned for twenty minutes later in the visit and then left again. Staff in charge, Gloria assisted with the remainder of the visit. The facility is licensed to serve 6 elderly , non-ambulatory residents, one of which may be bedridden, ages 60 and above. There is hospice waiver for 4. Bedrooms 1,2,3,4 and 5 are approved for non-ambulatory and bedroom 6 is approved for bedridden. There are currently no bedridden residents. Two residents are currently on hospice. The facility is a single-story home located in a residential area in Diamond Bar, Ca. A tour of the facility includes: living room, family room, kitchen, dining area, staff room, 6 bedrooms, 3 bathrooms (1 bathroom located in resident room), front yard, back yard with swimming pool and attached garage with laundry. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today’s visit and the initial visit and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility and a designated Infection Control Lead. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and training, and facility maintains the required current liability insurance. Physical Plant & Environment Safety: LPA toured facility. The facility is well maintained and walkways and hallways are free of debris and obstruction. Residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The required furnishings, light and bed linens were observed. There were extra linens and towels present. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. There is an inaccessible swimming pool at the facility. It has a taller than 5 ft fence and is locked. A shaded table and chairs were present to allow the residents to enjoy the outdoors. There are no security bars or weapons on the premises. The hot water temperature was measured within Title 22 requirements ( 105 F to 120 F) in resident bathrooms . All storage areas for cleaning solutions, toxins, knives, sharps and hazardous items are kept locked and are inaccessible to residents. Smoke detectors are present in each resident room and the living room. All were observed to be operable. A carbon monoxide detector was present and operable. There were 2 fire extinguishers present that was observed to be fully charged. Staffing : There appears to be sufficient staffing at all times in the facility. The night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training : Staff files are kept in a secure location. LPA reviewed 5 staff files. Files were reviewed for Criminal Record Clearance, Health Screening, Current First Aid and CPR as well as initial and ongoing training for care of the Elderly. No deficiencies were observed. Administrator’s certificate is current until 10/05/27. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Medical Consent, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 5 Resident Files and a deficiency was observed. See 809-D. Administrator advised to document when resident refuses inventory of personal items. Residents Rights-Information: Residents are provided with telephone and internet at the facility. All the required postings were observed. Planned Activities: Facility offers activities like singing for residents, coloring/drawing, chair exercises, a central TV viewing area for residents to enjoy together. Residents are taken outside for walks. There is an outdoor furnished patio area available for the residents. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Food was stored separately from cleaners, toxins and poisons. Appliances were observed to be operable and able to properly store and prepare food. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a locked closet and are in their original containers. LPA reviewed 4 residents’ medications and there was a defieciency cited. Please see 809-D. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Emergency food, water and portable oxygen were observed. A full First Aid kit and Manual were available. Last Disaster drill was documented on 04//02/25. Administrator to send documentation of disaster drills to LPA. Residents with Special Health Needs: 3 resident rooms were observed to have beds with bedrails. A defieciency was cited. See 809-D . Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. Facility admits residents with dementia and staff have all required training documented within personnel files. There are currently no bedridden residents. Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on the 809(D). Exit interview was held with staff in charge Gloria and a copy of this Licensing report was provided along with Appeal Rights.