Routine inspection·December 11, 2025

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 Administrator Joseph Cruz. LPA then met with RCFE Assistant Administrator Jacqueline Ortega, who arrived later. According to the facility’s license, the facility has a maximum capacity of forty (40) residents, of whom all may be ambulatory or non-ambulatory, and up to ten (10) may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of thirty-one (31) residents in care, of whom eighteen (18) were ambulatory, thirteen (13) were non-ambulatory, and none were bedridden. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter doors, and neither of these were present. 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 74 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: Bedroom #2 Sink was 118 F, Bedroom #5 Sink was 116.4 F, Bedroom #17 Sink was 119.1 F, and Bedroom #22 Sink was 111.2 F. The Walk-In Refrigerator and Walk-In Freezer, which are used to preserve perishable food, were both 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 and in good condition. There were no hazardous objects, toxic chemicals/poisons, active fireplaces, 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 other similar bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, 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) and staff had been trained on PPE within the last twelve (12) months. Licensee presented proof of current business liability insurance. During review of five (5) sampled resident records, LPA observed, and manager interview confirmed: For two (2) of these residents [Resident #1 (R1) and Resident #2 (R2)], Licensee did not have documented proof that the resident had an annual physical (“annual routine visit”) with their own licensed medical professional, within the last twelve (12) months, as required. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] For four of these residents [R1 through Resident #4 (R4)], Licensee did not have documented proof of the occurrence of a care meeting/conference with the resident and appropriate individuals, “to review and revise the resident’s written record of care,” within the last twelve (12) months, as required. Resident #5 (R5) was the only resident in care receiving outside hospice care services. However, Licensee did not have documented proof that R1’s hospice agency provided “training specific to the current and ongoing needs of the individual resident receiving hospice care…before hospice care to the resident begins,” as required. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] During review of five (5) sampled staff records, LPA observed, and manager interview confirmed: Licensee did not have documented proof that two (2) direct care staff [Staff #1 (S1) and Staff #2 (S2)] completed at least twenty (20) hours of annual training, of which at least eight hours were on dementia care and at least four hours were on postural supports, restricted health conditions, and hospice care, as required. Three (3) deficiencies was cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the LIC809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding disaster drills, specifically the requirement to vary the type of disaster covered from one quarter to the next (refer to the LIC9102-TV page). An exit interview was conducted with RCFE Assistant Administrator Jacqueline Ortega, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit. A copy of these same documents was also provided to Administrator Joseph Cruz.