Inspector’s narrative
What the inspector wrote
Licensing Program Analyst (LPA) Dang Nguyen conducted a return visit to continue a Required Annual Inspection that began on 12/16/2025. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Community Business Director Kitty Totorica. LPA also met with Resident Services Director Ashley Baino-Jaimes and Maintenance Director Omar Zamudio.
According to the facility’s license, the facility has a maximum capacity of one-hundred-eighty-five (185) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. Additionally, the facility has an approved waiver for ten (10) hospice care residents. Per LPA observation, care records, and staff interviews: During today’s inspection, there were a total of ninety-four (94) residents in care, of whom sixty-seven (67) were non-ambulatory, twenty-seven (27) were ambulatory, and none were bedridden. Two (2) of these residents were under hospice care.
LPA reviewed records for multiple residents and multiple staff. LPA interviewed multiple residents and multiple staff. LPA, accompanied by Licensee’s staff, also toured the interior and exterior of the facility, and inspected all common areas and multiple resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 72 F.
[CONTINUED ON LIC 809-C, 1 of 2]
[CONTINUED FROM LIC 809] Where tested, hot water temperature at taps accessible to residents were all compliant: Room #101 Sink was 111.9 F, Room #113 Sink was 116.1 F, Room #122 Sink was 111.7 F, Room #128 Sink was 115.3 F, Room #202 Sink was 113 F, Room #207 Sink was 117.5 F, Room #221 Sink was 107.1 F, Room #227 Sink was 114.4, Room #303 Sink was 108.1 F, Room #305 Sink was 107.4 F, Room #314 Sink was 107 F, Room #317 Sink was 109.2 F, Room #401 Sink was 106.9 F, Room #415 Sink was 108.9 F, and Room #425 Sink was 108 F. Appliances to preserve perishable food were also all compliant in temperature: Main Walk-In Refrigerator was 40 F. Freezers were 0 F. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present.
There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. No fireplaces, pools, or bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Fire detection system, carbon monoxide detectors, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguishers were serviced within the last twelve (12) months. Required licensing postings were observed in visible areas of the facility. Fire/disaster drills were performed at required intervals. There were reserve supplies of Personal Protective Equipment (PPE). Licensee presented proof of current business liability insurance.
During the facility tour, LPA observed, and manager interview confirmed: The facility has two (2) perimeter exit doors which have 15-second delayed-egress mechanisms. However, the facility’s existing Fire Clearance document (dated 02/15/2011) did not include approval for delayed-egress devices.
During a review of client records, LPA observed, and manager interview confirmed: For five (5) of five (5) sampled residents [Resident #1 (R1) through Resident #5 (R5)], Licensee did not have in their record of care the name, address, and telephone number of the residents’ dentist to be called in an emergency, as required. For one (1) of five (5) sampled residents (R1), Licensee did not have documentation that the resident received an annual routine visit (also known as an annual “physical” or “check-up”) with their respective licensed medical professional (or alternatively, documentation of the resident and responsible person’s refusal or such), as required.
[CONTINUED ON LIC 809-C, 2 of 2]
[CONTINUED FROM LIC 809-C, 1 of 2]
Three (3) deficiencies were cited per California Code of Regulations, Title 22 (refer to the LIC809-D pages). Plans of Correction were jointly formed with the Licensee. LPA also issued Technical Assistance (TA) regarding periodically measuring residents’ body weights and regarding specific skills training for direct care staff (refer to the attached LIC 9102-TA pages).
An exit interview was conducted with Maintenance Director Omar Zamudio and Dining Services Director Fernando Soto. A copy of this report, the LIC 809-D pages, the LIC9102-TA pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were during today’s visit. Copies of the same were E-mailed to Executive Director Julia Lopez, Resident Services Director Ashley Baino-Jaimes, Community Business Director Kitty Totorica, and Maintenance Director Omar Zamudio.
