Routine inspection·September 25, 2025

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with General Manager (GM) Billy Mitchell and Health Services Director (HSD), Jocelyn Bailon Saloche. During visit, LPA toured the facility with the HSD to include the common areas, kitchen, resident bedrooms, bathrooms, and exterior. Facility temperature maintained between 71 to 74 degrees F. All emergency exits were clear of obstruction. Activities calendar and menu posted in a visible area. It was observed that the only elevator in the facility that goes to Plaza (2nd and 3rd floor) had "out of order" signs posted. GM stated the elevators broke down yesterday on 09/24/2025 around 3:00pm. GM stated that they immediately called the vendor and had a technician come to the facility the same day around 4:30pm - 5:00pm. They were informed that the elevator is still functional however, the doors will not automatically close on its own but the elevator can be operated manually. GM states as of today, if any of the residents want to use the elevator, they need to call a staff to assist them in the elevator. GM states all the staff are trained on how to operate the elevator manually. In addition, they residents (who are able) and staff are using the stairwells. LPA observed the stairwells are equipped with evac chairs. GM states that they are offering in-room dining for residents who rather stay in their rooms and activities on the 2nd and 3rd floor of Plaza. GM is actively working with the vendor to fix the elevator. Page 1 of 2. Kitchen is supplied with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Items inside the refrigerator observed covered and labeled. Refrigerator temperature maintained at 39 degrees F. Freezer temperature was maintained at 8 degrees F. Staff stated they had the freezer opened which may have affected the temperature. The kitchen staff showed a log of the freezer temperatures which they monitor every morning, and logged below 0 degrees F. Toxins, chemicals and disinfectants are secured and stored separately from the food supply. A total of 9 resident bedrooms were observed. 9 resident bedrooms are equipped with beds, linens, night stands, dressers, and adequate lighting. Oxygen in use signs posted on the doors of residents who are using oxygen per physician's orders. Between 11:20AM - 12:30PM, the hot water temperature was measured in rooms #125B, 120, 118B, 203, 209, and 306 which measured between 132.6 - 136.4 degrees F. The maintenance personnel stated they had their water boiler serviced recently. During visit, facility had a plumber who was actively working on reducing the hot water temperature. At 4:26PM, the hot water was measured and observed maintained at 115.5 degrees F. 7 resident records were reviewed and observed complete and up-to-date. 5 out of 7 residents were on medication management. The 5 residents centrally stored medications and records were reviewed and all medications were accounted for. 5 staff files were reviewed and observed complete and up-to-date to include a background clearance. The staff are provided annual training on topics to include but not limited to dementia, Alzheimer's, prohibited and restricted health conditions, hospice, pressure sores, medications, caregivers, and blood borne pathogens. The facility is equipped with smoke and carbon monoxide detectors. Fire extinguishers were last serviced on 4/26/2025. LPA observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake/elopement drill log was reviewed and drills are being conducted quarterly. The last drill was conducted in August and September 2025. Facility has an updated emergency disaster plan and infection control plan. No deficiencies were cited today per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided.