Routine inspection·May 5, 2025

On May 5, 2025, at 8:00 AM, Licensing Program Analysts (LPAs) Edward Kim and Jessica Cho conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs met with Resident Service Director (RSD) Miriam Im. RSD Im called over the phone Executive Director (ED) Austin Morris who stated they would arrive to join the physical tour and LPA Kim explained the purpose of the visit. The facility is licensed to operate for one hundred fourteen (114) non-ambulatory, of which ten (10) may be bedridden, and maintains a hospice waiver for twenty (20) residents. The facility is a two-story structure, which consists of the following: one hundred twelve (112) resident bedrooms, thirteen (13) offices, one hundred sixteen (116) bathrooms, waiting area, hair salon, first floor activity area, second floor activity area, memory care dining room, main dining room, gym, kitchen, memory care courtyard, and two outdoor areas with outdoor covered patio. LPA Kim toured indoor and outdoor physical plant with RSD Im. ED Morris joined the tour around 9:00 AM. There is a fountain in one of the outdoor areas. All rooms were inspected. Beds and bedding supplies were in good condition with adequate lighting and refrigerator as well as storage for each resident’s personal belongings were observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The following resident apartments were inspected: 103, 107, 119, 140, 151, 156, 235, 260, and 274. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 106.7 degrees F and 114.2 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. 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). 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 inaccessible to residents. 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 and supplies are stored in the kitchen and in a storage room closet next to the kitchen. Emergency water is stored in a storage closet in Skilled Nursing across from room 183 and room 184. A working telephone (714) 844-0967 remains available. LPA Kim reviewed the facility’s plan of operation, emergency and disaster plan, and fire/safety drill log. The facility last conducted an Emergency Drill on April 28, 2025. The facility has fire extinguishers that are charged, and they were all serviced on October 4, 2024. Smoke detectors, and carbon monoxide detectors were operable and tested by CAL Building Systems on April 22, 2025. First Aid was maintained and contained all the necessary elements. Evidence of Liability insurance is effective on November 1, 2024, and expires on November 1, 2025. LPA Kim conducted an audit of nine (9) resident files (R1-R8), eight (8) staff files (S1-S8). LPA conducted six (6) resident interviews, four (4) staff interviews, audited medications for the nine residents. LPA discussed the following: to ensure that the medications are given according to the physician’s directions and Tuberculosis (TB) test result is maintained for S1. Based on today’s visit, deficiencies are being cited as per the Title 22 Division 6 Chapter 8 of California Code of Regulations (CCR). An exit interview was conducted, and a copy of this report and appeal rights were provided to Executive Director Austin Morris.