Routine inspection·March 19, 2025

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:00 AM, LPA Tea was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 152 ambulatory residents, of which 96 may be non-ambulatory, with a hospice waiver for 30 residents, and 30 maybe bedridden on the first and second floor. Currently there are 108 residents and 12 are on hospice during today's visit. The Executive Director (ED), Carmen Galicia is on leave. Business Office Manager (BOM) Lakhena Lor and Executive Director (ED) Kenya Carlton filling in for ED Galicia arrived shortly to assist with the visit. LPA Tea reviewed eleven resident files and seven staff files. Resident files and staff files contained all required documentation. LPA Tea along with BOM Lor toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a three-story building. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. The fire alarm system of the facility is monitored and maintained by a third-party company. Fire extinguishers are fully charged throughout the facility. Last disaster drill was conducted January 15, 2025. LPA observed evac chairs in every stairwell in the facility for emergencies. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 108.3 Fahrenheit degrees and 109.4 Fahrenheit degrees. LPA pulled emergency pendants in resident’s bathrooms; staff came in the room as promptly as they could. Common areas were clean and clear of hazards, doorways were free of obstructions. Facility kitchen and dining area was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed emergency food and water supplies stored in a room on the third floor. Annual inspection continued on LIC809-C LPA Tea observed residents eating in the dining room, watching TV in the TV room and reading quietly in the library. The facility provides different activities for residents daily, which are posted throughout the facility. LPA reviewed medication storage and administration. Medications are stored in locked carts in the medication room. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided. Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations An exit interview was conducted with BOM Lakhena Lor and a copy of this report was given to the facility along with a copy of the LIC858, 858C; 859, 859C and 9102TV.