Routine inspection·July 25, 2025

On July 25, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Executive Director (ED) Enrique Ledesma and explained the purpose of the visit. The facility is licensed to operate for eighty (80) non-ambulatory, of which seventeen (17) may be bedridden, and have a hospice waiver for fifteen (15) residents. Facility is approved for delayed egress and secure perimeter, and a waiver for locked perimeter gates. The facility is a single-story structure, which consists of the following: fifty-four (54) resident bedrooms, six (6) office rooms, thirty-eight (38) bathrooms, waiting area, activity area, dining room, kitchen, and two (2) outdoor covered patio areas. LPA Kim toured indoor and outdoor of the physical plant with ED Ledesma. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The following bedrooms were inspected: Resident Room 102, Resident Room 203, Resident Room 206, Resident Room 207, Resident Room 208, Resident Room 302, Resident Room 305, Resident Room 402 and Resident Room 406. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 110.4 degrees F and 117.5 degrees F. A comfortable temperature of 75 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food is stored in the kitchen. Emergency water and emergency supplies were stored in a storage closet. A working telephone (714-577-8005) remains available and is dedicated to the residents. LPA Kim reviewed the facility’s plan of operation, emergency and disaster plan, and fire/safety drill log. The facility conducted a Fire/Safety Drill on June 15, 2025. The facility has eleven (11) fire extinguishers that were charged and they were all serviced on September 5, 2024. All smoke detectors and carbon monoxide detectors were operable and last checked on October 29, 2024, by Orange County Fire Authority. First Aid was maintained and contained all the necessary elements. Certificate of Liability insurance is effective October 10, 2024, and expires on October 10, 2025. LPA Kim conducted an audit of eight (8) resident files (R1-R8), eight (8) staff files (S1-S8), and medication and medication administration record. LPA observed R1’s medical assessment dated June 25, 2024, and was diagnosed with dementia. LPA also observed S1, S2, and S3 did not complete twenty hours of training for 2024. LPA conducted six (6) resident interviews and four (4) staff interviews. A deficiency was cited during the visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8). The annual twenty hours of staff training for three out of eight staff (S1, S2, and S3), were not completed. A technical violation was assessed during the visit. LPA observed R1, diagnosed with dementia, did not have a current medical assessment for 2025. The last medical assessment was dated June 25, 2024. An exit interview was conducted, and a copy of this report, LIC811, LIC809D, and appeal rights were provided to Executive Director Enrique Ledesma.