Routine inspection·December 12, 2025

Licensing Program Analysts (LPAs) Brian Balisi and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at approx 9:00 a.m. Upon arrival, LPAs were greeted by the front desk receptionist and explained the reason for the visit.  LPA's met with Executive Director Connie Smiley shortly after. At approx 09:40 a.m. LPAs along with Executive Director Connie Smiley, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: LPAs inspected the kitchen/food service area.  Knives are stored and inaccessible to residents. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. A sufficient amount of emergency food was observed properly stored. The furniture in the common areas were observed to be clean and in good condition. The facility maintained a comfortable temperature. LPAs observed required postings throughout the common space. At approx 10:06 a.m LPA's observed that One (1) out of (3) Stairwells did not have an emergency evacuation chair. LPA's did not observe any obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. LPAs observed multiple randomly selected  resident bedrooms on the first and second floor. All resident bedrooms were furnished appropriately and had sufficient lighting.  All resident restrooms appeared to be clean,  sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels.  The hot water temperature was measured  between 109– 117 degrees Fahrenheit. Continued from 809 The LPAs observed appropriate outdoor furniture, with a covered shaded area for resident use. The facility maintained a comfortable temperature of 73 degrees. LPAs observed cameras throughout the common areas. LPA's requested to review live and recorded footage and observed that the audio components were disabled on each video.  Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA’s reviewed five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.  All records were in order at this time. LPA's reviewed Personnel records, five (5) personnel files. File's were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. Medications review . All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file.  Medication appeared to be given as prescribed at the time of the visit. At approx 12:37 p.m. LPA's observed four (4) residents that had their medications stored in pre-poured cassettes stored for at least (2) weeks. Three (3) out of (4) of these residents did not have prescription orders on file for review. Infection Control Plan / Emergency Disaster Planning: During today's visit, LPAs reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced 01/21/2025.  Emergency disaster drills conducted quarterly as per regulation; the last fire drill was conducted on 12/06/2025. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties. During today’s visit LPA obtained a copy of the facility’s LIC 500 and resident roster. Exit interview conducted, appeal rights discussed and copy of the report was issued.