Routine inspection·November 17, 2025

At approximately 10:00am Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection visit and was greeted by Program Administrator (admin) Shelley Reyes. Facility is a Residential Care Facility for the Elderly (RCFE) with currently one hundred and seven (107) residents in care. Facility has a hospice waiver for twelve (12), a bedridden waiver for thirty (30), and is approved for all non-ambulatory residents. LPA and admin toured the buildings and grounds. Facility found to be at a comfortable temperature. All passageways and emergency exits were free from obstruction. LPA observed evacuation chairs on both stairways. Admin opened chairs and were observed to be functional. Elevator was operational and functional. Alarm system in exit door heading toward courtyard had minimal low volume, not loud enough to summon staff. Batteries were replaced. In addition, signal system heading toward back parking lot exit next to restrooms was not turned on. (Deficiency cited, see LIC 809D). Facility's fire extinguishers were observed charged and were last serviced 12/2024. Facility's fire system is hardwired though fire department. Four (4) water heaters throughout facility. Ten (10) residents' apartments were inspected and water temperatures in Residents' bathrooms and communal bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. Residents' bedrooms were inspected and observed to be clean with all the appropriate furnishings. The call system was tested in four (4) resident's rooms. Caregiver response time was 6 minutes and 17 seconds, 1 minute and 33 seconds, 1 minute and 50 seconds and 3 minutes and 50 seconds. Storage rooms containing cleaning supplies and other items that could pose a risk were locked. Continued to 809C... continued from 809... Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Facility kitchen and walk-in refrigerator and freezer were inspected and all food is being properly labeled and stored. LPA observed activity rooms including theater room, puzzle room and library room to be accessible for residents to use. Seating areas were observed in multiple outdoor courtyard spaces throughout the facility for activities. Facility has two transportation vehicles including a bus and van for resident outings. LPA observed fire extinguishers up to date and last serviced 12/24. LPA observed first aid kit in both vans to have multiple expired items (Technical Violation given). Admin showed proof of order receipt for first aid kits to be replaced for both cars. LPA reviewed nine (9) staff files and ten (10) resident files. All staff files reviewed have all of the required paperwork, proof of current First Aid and CPR training, and proof of all required training hours. Training certificates not placed in employee files, admin to send certificates to LPA by 11/19/25. Ten (10) of ten (10) resident files reviewed have all the required paperwork. LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. Facility does not handle residents P&I monies. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit : LIC500 Personnel Report LIC308 Designation of Responsibility Liability Insurance Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations, may result in a civil penalty assessment. Appeal rights provided to Administrator .