Routine inspection·September 25, 2025

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1 Year Annual evaluation. LPA was greeted and granted entry by Licensee Tricia Pedroza followed by Administrator (Admin) Ephantus Warui after explaining the reason for the visit. The certificate for Admin Warui is currently valid expiring on June 9, 2027. The following was observed during the tour: This is a two story building comprised of an Assisted Living (AL) and Memory Care (MC) unit on the first floor with AL on the second floor. Facility operates within the conditions and limitations specified on the license as there were 151 residents in care of which 7 were under hospice. LPA toured the physical plant accompanied by the Admin. Facility is clean, sanitary, odorless, and in good repair. LPA inspected all common areas which includes but is not limited to: the storages, activity rooms, television rooms, community shower/bathrooms, kitchen, dining, and medication room. LPA inspected 3 MC and 2 AL resident units on the 1st floor with 5 more AL units on the second floor which is a total of 10 units. The residents' units were appropriately furnished, beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage space for each residents' personal belongings were observed. All bathrooms were found to be in compliance, clean, and operational. However, the hot water temperature exceeded 2-3 degrees in four out of the ten apartment units measuring at 123.8, 123.6,122.3, and 120.2 degrees Fahrenheit which was readjusted during the visit. Admin agreed to adjust accordingly to ensure temperature is within the required range. Toxins, disinfectants, and sharps were secured and inaccessible. However, medications that Resident #1 (R1) self manages in their shared apartment was accessible to Resident #2 (R2), who is not allowed to store and administer their own medications. Violation exists. LPA observed ample two-day supply of perishables and seven-day supply of non-perishable food. LPA observed emergency food and water in the closet. The fire extinguishers were mounted, fully charged, and serviced on both levels on August 20, 2025. LPA tested the auditory devices in the residents' rooms that were available and carbon monoxide detectors were found operational on both levels. Per review of the 5 year inspection report conducted on September 4, 2024, smoke detector testing passed. Admin also indicated that fire alarm system is monitored by the company in real time evidenced by the green lights on the panel which indicated operational. The outside grounds were clear of hazards and there were sufficient seating in a shaded area. Emergency drills are conducted quarterly with the last date on September 20, 2025. The Complaint Poster (PUB475) was posted in the correct size behind the reception desk. LPA reviewed 11 resident files and four personnel files in which no discrepancies were found. Interviews were conducted with five residents and two staff. The following were advised: to ensure medications are locked in shared units if one of the resident is unable to manage their own medications and to ensure hot water temperature is regulated between 105-120 degrees Fahrenheit. Based on the observations, a deficiency is being cited, and a Technical Violation is being issued. An exit interview was conducted with Administrator Ephantus Warui, and a copy of this report including the appeal rights were provided at exit.