Routine inspection·October 31, 2025

Licensing Program Analyst (LPA) Kelly Dulek conducted a required annual visit and discussed a recent self reported incident sent to Community Care Licensing on 10/28/2025 involving Staff #1 (S1) and Resident #1 (R1). LPA was greeted by the receptionist upon arrival. LPA met with the family liaison and wellness coordinator and explained the reason for the visit. LPA requested documents for review. Administrator SanJuana Joanna Enriquez arrived at 10:23AM. Entrance interview conducted. At 11:04AM, LPA along with Administrator and family liaison 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 noted: The facility is a 3-story building, with common areas and resident rooms on all three (3) floors. The facility's memory care unit is located on the first floor and there are Assisted Living resident rooms on all three (3) floors. BEDROOMS: LPA inspected ten (10) resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. LPA observed a sufficient supply of towels and linens. RESTROOMS: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. Hot water temperature was measured in various rooms in both the memory care and assisted living units and ranged from 106.2 degrees to 110.2 degrees Fahrenheit, which is within the required range. Report Continued on LIC 809C COMMON AREAS: Common areas include a theater, activity rooms, therapy room, game room, sweet shop, and dining room. Furniture in the common areas was observed to be in good condition. Carpet throughout the building was observed to be dirty and/or stained. Administrator stated the facility just purchased a carpet extractor, which will allow the facility to clean their carpets more thoroughly and regularly. The facility maintained a comfortable temperature throughout the visit. The fire extinguishers were fully charged and were last serviced May 6, 2025. LPA observed required postings throughout the common space. LPA observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. The facility has an adequate supply of Personal Protection Equipment (PPE). The facility has a fenced in pool in the courtyard that has two locked gates. There was patio furniture and shade for residents. KITCHEN: LPA inspected the kitchen/food service area, which is shared between this facility and the neighboring Skilled Nursing Facility. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food as well as an emergency supply of food and water kept in supply rooms on the third floor. Refrigerator and food pantry were checked for proper labels and expiration dates. RECORDS: LPA reviewed five (5) resident records; all records were complete. LPA reviewed five (5) personnel records; all records were complete. EMERGENCY DISASTER PLAN/INFECTION CONTROL PLAN: LPA reviewed the facility emergency disaster plan and infection control plan, both of which were complete and updated annually as required. The facility conducts monthly evacuation drills. Each month the drills are conducted during a different shift in order to meet quarterly training requirements. MEDICATIONS: Due to time constraints, medications will be reviewed during the annual continuation visit. DOCUMENTS OBTAI NED : LPA obtained a copy of the facility's resident roster, personnel roster, and current liability insurance. LPA also reviewed and obtained copies of documents for R1 and S1 relevant to the self-reported incident. INTERVIEWS: LPA interviewed three (3) residents and four (4) staff; no concerns were noted. LPA will return at a later date to continue the annual inspection and to conduct further investigation into the self-reported incident. No citations issued. Exit interview conducted. A copy of today's report was provided.