Routine inspection·April 29, 2026

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required 1 year inspection and met with Associate Executive Director/Administrator (AED) Val Baldugo and stated the purpose of the visit. Executive Director/Administrator (ED/ADM) arrived at a later time. The facility serves adults ages 60 and over, 140 non-ambulatory, 21 may be bedridden and hospice waiver for 15. LPA toured the interior of the facility, including entryway, lobby, resident room hallway, common area, dining area, kitchen, fire escape staircase, laundry room, emergency food supply area, medication room, activity area, 6 Assisted Living (AL) resident rooms, and 4 (2 shared & 2 private) Memory Care (MC) resident room and bathrooms. LPA observed that designated emergency exits are clear from obstruction and tripping hazard, however, LPA observed yellow caution tape on the entry ways due to ongoing exterior facility maintenance. Facility is a three story building, reception lobby where most residents sits, socialize, meet friends, and wait for their transportation. The exit doors are equipped with wander guard that alerts staff for resident who have exit seeking behaviors. Facility has activities scheduled posted for the whole month of April and posted conspicuously in the facility hallways, dining area, elevator, hallways, residents in the AL area received monthly activity calendar of events. LPA observed residents participating during one of the activity time in the MC and the AL area. page 1 of 2 MC area of the facility is equipped with delayed egress and working audible alarms. LPA observed rodent traps under the counter cabinets of the MC Unit. LPA did not observe any food stored that may be attracting the rodents. AED stated that the counter top with the food warmer is not in use. The facility kitchen is equipped with walk-in commercial grade refrigerator and freezer. Doors going to the kitchen have locks when not in used and are not accessible to residents. LPA observed emergency drinking water supply, 7 days for non-perishable food and emergency food supply (easy to prepare meal). The facility has snack bars in the activity areas. The kitchen is kept sanitary and organized. LPA inspected the freezer area, and observed that the facility has sufficient perishable food supply for 2 days or more. The walk-in refrigerator and freezer is cleaned 3 times or more a week. The dishwashing area and hot water temperature delivers over 125 degree F and warning sign is posted that the tap delivers hot water over 125 degree F. Kitchen staff were observed sweeping, wiping surfaces and organizing the kitchen after morning meals were served. LPA observed the dining area floors are kept sanitary. There were residents still present at the dining area at the time of inspection. The refrigerator temperature is at 31 degree F and the freezer temperature is at 0 degree F. LPA inspected assisted living (AL) residents room and memory care (MC) resident room. LPA observed that resident rooms have sufficient storage space for their personal belongings. Based on 5 out of 5 staff interviews, AL and MC are cleaned once a week and laundry are done once a week. Unless otherwise necessary, such as emergencies and behavioral challenge such as but not limited to smearing food and throwing food. The caregivers, and medication technicians will step in to keep the residents room in a safe and sanitary condition to prevent any infestation of ants and other insects, especially when housekeeping is not available. Based on review of the admission agreement extra cleaning for the week will incur a fee. The resident rooms were observed to be sanitary and organized. The AL and MC hot water temperature were measured with a digital thermometer, the temperature ranges between 115 degree F to 118.9 degree F. page 2 of 3 LPA conducted 5 staff interview and interviewed 5 residents in the AL area and 1 in the MC area. LPA reviewed 10 staff record for current training, background clearance, personnel file and current certifications. LPA reviewed 10 resident record such as individual care plans, physician's report (LIC 602), personal rights, admission agreement, consent forms to name a few. Medication record will need to be reviewed at a future date due to time constraint. LPA conducted a facility file review and verified that the facility conducts the fire and disaster drill training each month and given by Fire Safety Service, Inc. The last drill training was given on 04/13/2026. The facility maintains Ecolab to monitor and exterminate possible pest in the MC area. Based on record review Ecolab comes to the facility each month and or as needed to monitor the traps set at the MC kitchen area. The facility has fire extinguishers that are strategically placed in each floor and were last inspected on 05/15/2025 and 05/19/2025. The facility is equipped with fire alarm and carbon monoxide alarm system. The facility has a fire alarm panel that alerts the fire department in case of a fire. The facility is equipped with manual wet standpipe to be used in case of fire and water sprinklers. The facility ha emergency evacuation chairs for each fire escape staircase. Due to time constraint the required 1 year annual inspection will be continued at a later date. No deficiency was cited during today's annual required visit. An exit interview was conducted with Executive Director/Administrator (ED/ADM) Karina Nevarez and Associate Executive Director (AED) Valerie Baldugo and a copy of the report was provided. page 3 of 3