Routine inspection·September 25, 2025

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) Marivel Johnson. The facility's license shows a maximum capacity of 249 residents, 85 of whom may be non-ambulatory. Additionally the facility is approved for twelve (12) hospice waivers. During today’s inspection there were 222 residents in care. Note, LPA did step out for lunch from 12-1pm. LPA, ED Johnson, and Director of Environmental Services Arturo Vega toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at sampled taps accessible to clients were all compliant: Bathroom sink in a unit of the Villas building was read at 105.6F and water temperature in a bathroom sink of the Casa Loma building read at 106.8F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. The facility is about to undergo a remodeling of their main kitchen and a temporary mobile kitchen was developed and will be used during construction. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. The facility maintains two (2) separate medication rooms and LPA examined the one belonging to the Casa Loma building. One pool does exist on the premises and LPA observed it to feature a secured perimeter as required per regulation. Additionally the facility features a small fountain display in an open courtyard, though no pool or body of water is part of it, thus not making it a drowning risk. Per ED Johnson, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. During the tour of the property, LPA observed fire alarms being tested in the Cottages building. Fire extinguishers were serviced within the last 12 months -- dated for August 2025. Last staff emergency drills were conducting on 9/10/25 for the topics of fire and earthquakes. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed zero (0) staff and three (3) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with ED Johnson to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.