Routine inspection·January 15, 2026

Licensing Program Analysts (LPAs), Martha Arroyo and Brian Balisi conducted an unannounced annual inspection today. Upon arrival, the LPAs met with Executive Director (ED) Helen Lee and the reason for the visit was explained. Entrance interview. Starting at 10:30am, the LPAs along with the ED, 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: Kitchen: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. The LPAs observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day supply of food and water. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. An adequate amount of emergency food and water was observed; properly stored. Resident Rooms / Restrooms: The LPAs observed six (6) resident rooms in the assisted living side and two (2) resident rooms in memory care. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:39am, the hot water temperature was measured in eight (8) resident bathrooms, and the temperature measured between 112.9 – 118.8 degrees Fahrenheit. Report Continued on LIC 809C... Report Continued from LIC 809... Common Areas: The LPAs observed common areas to be clean and in good condition. There are games and/or activity supplies in the activity rooms as well as throughout the facility. There was sufficient space to accommodate both indoor and outdoor activities. The facility maintained a comfortable temperature. Required postings were observed throughout the common space. The LPAs observed stairwells to have emergency evacuation chairs. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced on 12/06/2025. Outdoor Space: The LPAs observed the outdoor garden in Assisted Living and Memory Care which had shaded seating areas for resident use. All passageways were observed to be clear and free of hazards. Record Review: The LPAs reviewed seven (7) resident records and seven (7) staff records starting at 11:31am. Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All records were in order. Personnel files including the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments with TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files were in order. During today’s visit, the LPAs conducted interviews with five (5) staff and two (2) residents. No concerns were noted. Report Continued on LIC 809C... Report Continued from LIC 809C... Medication Review: The LPAs reviewed medications at approximately 12:10pm. Medications are centrally stored in the medication room on the 2nd floor. The LPAs reviews six (6) randomly selected resident’s centrally stored medications. Medications were properly documented on the centrally stored medication & destruction record and appear to be given as prescribed at the time of the inspection. During today’s visit, the LPAs reviewed the facility's infection control policy as well as their emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Daily vehicle inspection list were reviewed for facility vehicles. The last fire safety inspection was completed on 12/02/2025 and was found to be in compliance with Fire Code Regulations at the time of inspections. Emergency disaster drills conducted quarterly as per regulation; last disaster drill conducted on 12/10/2025. No citations issued. Exit interview conducted. Report was reviewed and copy provided.