Routine inspection·March 27, 2026

Licensing Program Analyst (LPA) Dang Nguyen made an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrative Assistant Jasmine Ybarra. LPA then met with Administrator Susan O’Shaughnessy, who arrived shortly after. According to the facility’s license, the facility has a maximum capacity for one-hundred-ten (110) residents, of whom all may be ambulatory or non-ambulatory, and up to ten (10) may be bedridden. Also, up to twenty (20) of the residents may be under hospice care at any given time. Per LPA observation, LIC602 Physician’s Reports, and manager interviews: During today’s inspection, there were a total of forty-nine (49) residents in care, of whom thirty-four (34) were non-ambulatory, and one (1) was bedridden. Also, eight (8) of the residents were under hospice care. The facility’s license and fire clearance allowed for the use of locked perimeter doors in the memory care unit, and such doors were compliant with this stipulation. LPA reviewed records for multiple residents and multiple staff. LPA interviewed multiple staff. LPA, accompanied by the administrator, 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 75 F. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] Where tested, hot water temperature at taps accessible to residents were compliant. Appliances to preserve perishable food were also all compliant in temperature: Main Walk-In Refrigerator was 37.7 F. Main Walk-In Freezer was 0 F. The Medication Room Refrigerator was also complaint in temperature. 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 or pools (or similar 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. Licensee presented proof of current business liability insurance. During a review of records, LPA observed, and manager interview confirmed: For 1 of 5 sampled residents [Resident #1 (R1)] Licensee did not possess proof/documentation that the resident had a negative tuberculosis test result or chest X-ray, as was required to be on file before the resident’s move in. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] For 4 of 5 sampled residents [Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5)], Licensee did not have as part of the resident’s record the name, address, and telephone number of a dentist to be called in an emergency, as required. For R2, Licensee also did not have as part of resident’s record the name, address, and telephone number of a physician to be called in an emergency, as required. Licensee did not have proof/documentation that within the last twelve (12) months, they held a meeting/conference with the responsible person and other appropriate parties for 5 of 5 sampled residents (R1 through R5), for the purpose of reviewing and updating the resident’s written record of care / care plan, as was required. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] Licensee did not possess an LIC610E Emergency and Disaster Plan that met current regulatory requirements. Licensee also did not possess documentation demonstrating that either a consultant pharmacist or nurse had reviewed the facility’s medication management program and procedures at least twice per year, which is a requirement for residential care facilities for the elderly licensed to provide care for 16 or more persons. Three (3) deficiencies were cited per California Code of Regulations, Title 22, and two (2) deficiencies were cited per California Health and Safety Code (refer to the attached LIC809-D pages). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Administrator Susan O’Shaughnessy, to whom a copy of this report, the LIC 809-D pages, and the LIC811 Confidential Names List were provided during today’s visit.