Inspector’s narrative
What the inspector wrote
On 10/23/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a follow up a case management visit regarding the deficiencies observed during a complaint investigation (# 27-AS-20250804095207) visit on 08/06/25. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator / Executive Director (ED). LPA met with ED Jonathan Aguilar and Ashley Sylve the Quality Assurance/Performance Improvement Director (RQAPID). A brief meeting followed.
During this LPA's tour of the facility on 08/06/25, this LPA observed the following:
LPA observed an unlocked laundry room with toxic chemicals accessible to residents in care. LPA also observed Clorox bathroom cleaner and Crest mouth wash under the sink in room (#37). These were violations of the California Code of Regulation (CCR) 87309, "Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage."
This LPA also observed the door to the Medication Room in Assisted Living was open and the keys to the medication cart were in its lock. No staff were present in the medication room or the room that was being used as an office attached to it. This was a violation of CCR 87465 "Incidental Medical and Dental, "(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible
for the supervision of the centrally stored medication."
When this LPA toured the facility and tested the rear delay egress door in the Memory Care Community, the door opened without delay and the alarm did not sound. This was a violation under Health and Safety Code, "1569.699(a) Exit doors; egress-control devices of time-delay type; fences. H&S 15699(a) states, "(a) When approved by the person responsible for enforcement, as described in Section 13146, exit doors in facilities classified as Group R, Division 2 facilities under the California Building Standards Code, licensed as residential care facilities for the elderly, and housing clients with Alzheimer’s disease or major neurocognitive disorder, may be equipped with approved listed special egress-control devices of the time-delay type, provided the building is protected throughout by an approved automatic sprinkler system and an approved automatic smoke-detection system. The devices shall conform to all of the following requirements:…"
LPA observed that both the entrance door to the Business Office, and its interior door to the smaller office within, were open and a file drawer was left open leaving residents confidential financial information accessible. This was a violation under Additional Personal Rights of Residents in Privately Operated Facilities CCR, 87468.2 "(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law."
These deficiencies were cited on the attached LIC 809D pages.
LPA also observed during today's visit that an Activities Director/Life Enrichment Coordinator has not been hired yet. The previous person was laid off in September. LPA asked the ED what plans were in motion to fill the position. LPA provided technical assistance and referred to CCR Planned Activities
87219
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:
(1) Socialization to promote or enhance personal relationships. Activities may include, but are not limited, to:
(A) Group discussion and conversation.
(B) Reminiscence activities, such as looking at photos, letters, or greeting cards.
(C) Cultural and/or religious activities, such as holiday celebrations and cultural traditions.
(D) Other social activities such as arts, crafts, games, gardening, pet care, and other recreational activities promoting social interaction.
(2) Daily living skills/activities which foster and maintain independent functioning.
(3) Cognitive and mental stimulation activities such as reading, writing, movies, crossword puzzles, board and card games, and using the computer.
(4) Sensory stimulation, such as music therapy and aromatherapy, or tactile activities, such as pet therapy. (5) Leisure time activities cultivating personal interests and pursuits, and encouraging leisure-time activities with other residents.
(6) Physical activities that maintain physical health including
games, sports, exercises, and other similar activities that promote balance, strength, coordination, flexibility, and range of motion.
(7) Education, achieved through special classes or activities.
(8) Provision for free time so residents may engage in activities of their own choosing.
(b) Residents served shall be encouraged to contribute to the planning, preparation, conduct, clean-up and critique of the planned activities.
(c) The licensee shall arrange for utilization of available community resources through contact with organizations and volunteers to promote resident participation in community-centered activities which may include:
(1) Attendance at the place of worship of the resident's choice.
(2) Service activities for the community.
(3) Community events such as concerts, tours and plays.
(4) Participation in community organized group activities, such as senior citizen groups, sports leagues and service clubs.
(d) In facilities licensed for seven (7) or more persons, notices of planned activities shall be posted in a central location readily accessible to residents, relatives, and representatives of placement and referral agencies. Copies shall be retained for at least six (6) months.
(e) In facilities licensed for sixteen (16) to forty-nine (49) persons, one staff member, designated by the administrator, shall have primary responsibility for the organization, conduct and evaluation of planned activities. This person shall have had at least six (6) months experience in providing planned activities or have completed or be enrolled in an appropriate education or training program.
(f) In facilities licensed for fifty (50) persons or more,
one staff me
mber shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. The program of activities shall be written, planned in advance, kept up-to-date, and made
available to all residents. The responsible employee shall have had at least one year of experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers.
LPA requested a plan be submitted to Community Care Licensing for how/when the facility will fill the full-time 40 hour, on site, position ensuring that the candidate meets all of the qualifications required in Title 22.
According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS, and an exit interview was conducted with Aguilar and Sylve.
