Routine inspection·December 9, 2025

Licensing Program Analyst (LPA’s) E. Conchas and LaVette Farlow made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Maria Cervantes, Administrator Assistant who assisted with the tour of the facility. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature 75 de g rees throughout the facility. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. The hot water temperature measured at 124.7, 119.7, and 123.5 degrees F. throughout the facility. LPA observed the facility is equipped with operating smoke detectors, fully charged fire extinguisher, and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. LPA observed there was a designated storage space for resident/staff files. Medications are kept locked in the medication room inaccessible to residents in care. LPA audited and observed 4 resident MARs with discrepancies a Technical Assistance was issued. LPA observed Family Council, Long Term Ombudsman Rights Of Individual , Menu, and Activities Calendar in display. Overall, the facility is clean, in good repair, and operating in safe condition. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review : LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed Physician Report information was not filled out completely a Technical Assistance was issued. P&I was randomly checked and appeared to balance with ledger. Emergency disaster plan should be updated annually or as changes made and Plan Of operation should be updated when retaining bedridden residents and or changes to hospice A Technical Assistance was issued. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Based on the observations made during today’s visit, 4 Technical Assistance were issued. An exit interview was conducted, and this report was discussed and provided to Maria Cervantes, Administrative Assistant and Dori Loo, Director Of Operations and Clinical Services at the conclusion of the visit with appeal rights.