Routine inspection·October 9, 2025

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. LPA met with Executive Director Kimberly Sanchez. 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 74 non-ambulatory residents, of which 4 may be bedridden. A hospice waiver for 15 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 4/1/2026. Physical Plant/Environment Safety: The facility is two 2-story building consisting of "Evergreen" Memory Care Unit , 52 resident rooms, 2 activity rooms, 2 dining rooms, kitchen, dining room, 2 bathique rooms, two TV rooms, library, Bistro room, hair salon, administration offices, laundry rooms, storage areas, 1st floor courtyard/patio area with water fountain, 2nd floor terrace area, courtyard patio area, electrical rooms, staff break room, and parking garage. The interior and exterior physical plant was inspected. Twenty (20) resident rooms, common areas, and kitchen were inspected. Resident rooms have required furniture, bedding, linens, and lighting. 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. The last fire inspection was conducted on 4/30/25 by Pasadena Fire Department. Staffing: A total of 69 staff members provides care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 8/5/2027. Staff have criminal background clearance. Nine (9) staff files were reviewed. They contained 1st Aid/CPR training, criminal background clearance, health/TB screenings, 1st Aid/CPR training, and training records. 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. Planned Activities: Facility activity calendar was posted. 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. 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 9/17/2025. Residents with Special Health Needs: There are currently 9 residents receiving hospice services, 7 residents receive home health services, and no residents have prohibited health conditions. Individual Service Plans, Appraisals, and postural support physician orders are on file. No deficiencies were cited. Exit interview was conducted with Kimberly Sanchez. A copy of report was issued.