Routine inspection (multi-day)·October 7, 2025

At 9:30am, on 10/7/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct a Case Management - Annual Continuation to continue the annual inspection started on 9/16/2025. LPA met with Administrator Audie Sherberg, announced who he was and the reason for the visit. LPA and the Administrator in Training Erika Consebida and the Maintenance Supervisor conducted a full tour of all three floors of the facility. The first floor contains the main lobby, staff room, administrative office spaces, kitchen, dining room (with communal, private and outdoor dining areas), an activities room, seventeen resident bedrooms, and an outdoor courtyard in the middle with seating and shade for residents and visitors. The second floor has a beauty salon, medication room, a common area with seating and a full kitchen for cooking activities, twenty-six resident bedrooms, the laundry room through a locked door for resident safety and an outdoor patio space overlooking the central courtyard with seating and shade. The third floor includes, an activity room, twenty-one resident bedrooms, and an outdoor terrace overlooking the east side of the surrounding area with seating areas. All resident bedrooms have an on-suite bathroom and a kitchenette. LPA tested facility hot water in several bedrooms throughout the facility ranging from 109.5 - 115.6*(f), within regulation temperatures 105*-120* (f). The main kitchen faucets are not used by residents and deliver water hotter than 125*(f) and the faucets are marked with signage indicating the hot water per regulation. LPA observed at least 2 - days of perishable and at least 7 - days of nonperishable foods in the main kitchen. Each floor has community use restrooms. The facility has two elevators, serviced on 6/27/2025 and emergency evacuation chairs at the top of the two stairwells. LPA noted that the facility is in good repair with no obstructions in hallways, doorways or exits. (Continued on LIC9099-C) The facility offers activities to all residents in care. Daily activities are displayed on a white board next to the reception desk and a monthly activity schedule is provided in print to the residents. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records (CSMR), finding eleven medications of the five resident CSMRs reviewed not documented. Staff stated if the LPA audited all the resident CSMRs who receive medication administration assistance from the facility the LPA would find more medications not documented per regulation. The facility employs approximately 67 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed a sample number of staff files for current 1st Aid/CPR, Health screening with TB results, training and fingerprint clearance. Administrator has current certification. While reviewing medication technician training required by the California Health and Safety Code (HSC) the facility could not provide the required annual training documentation for any of the medication technicians and the Vice President of Operations Lisa Hulse stated they do not have their current required training. Lisa stated the facility is currently working with a new training company to provide all required initial and annual staff training. The facility keeps separate files on each resident confidentially. LPA reviewed a sample number of resident files for signed Admission Agreements and Appraisals/Reappraisals. LPA and Administrator conducted a review of the annual care tool modules. Citations issued at this time. Exit interview conducted, deficiencies cited on the LIC809-D page, report signed, and report provided to the Administrator.