Routine inspection·March 3, 2026

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. LPA met with med-tech Mylene Cho. Administrator/LVN Tammie Cha arrived later. 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 facility has an Infection Control Plan. Operational Requirements: The facility has an approved fire clearance for 142 non-ambulatory residents, of which 4 may be bedridden. A hospice waiver for 20 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 10/24/2026. Physical Plant/Environment Safety: The facility is a 4-story building with 71 resident rooms, a Memory Care unit located on the 2nd floor, laundry rooms in each floor, medication room, kitchen, dining room/activity rooms located in each floor, library, administration offices, outdoor side yard patio area, and basement parking garage. The interior and exterior was inspected. All common areas and 26 rooms were inspected. Resident rooms have required furniture, bedding, linens, and lighting. However, the majority of resident beds do not have mattress pads. The signal system was tested and is operational. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. Cleaning supplies and toxic substances are inaccessible to residents. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has fire extinguishers. Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. Two knives and two scissors were observed in the Memory Care Unit unlocked refrigerator freezer. Exit doors are free of any obstruction. The last fire inspection was conducted on 2/13/2026 by CV Fire Protection, Inc. Staffing: A total of 39 staff members provide care and supervision of residents. Personnel Records/Staff Training: Administrator certificate expires 3/2/2026. 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. R1, R5, R6 & R7 have have medical assessments that are more than 12 months old. Planned Activities: Facility activity calendar was posted. Sufficient space to accommodate both indoor and outdoor activities was observed. RCFE & Ombudsman complaint posters are posted. 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. Breakfast meals are cooked on site and lunch and dinner meals are prepared by an outside catering company. Kitchen personnel have current food handling certificates. 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. Vitamins were found unlocked in R2's room without a physician order. 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 2/19/2026. Residents with Special Health Needs: There are currently 4 residents receiving hospice services, 27 residents 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 Title 22, deficiencies were observed and are cited. Exit interview was conducted with Tammie Cha. A copy of report and appeal rights were issued.