Health inspection·January 21, 2026

§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. §72523 Patient Care Policies and Procedure (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. §72637 General Maintenance. (f) The facility shall be maintained free from vermin and rodents through operation of a pest control program. The pest control program shall be conducted in the main patient buildings, all outbuildings on the property and all grounds On 12/9/2025 the California Department of Public Health (CDPH) received a complaint alleging the presence of cockroaches observed in the residents' rooms crawling on the wall, on medical equipment and on a resident's nightstand on 11/25/2025 and 12/4/2025. On 12/10/2025, the CDPH conducted an unannounced visit to the facility to investigate the complaint. During the investigation, the CDPH determined the facility had a cockroach infestation. The facility failed to: 1. Ensure sanitary conditions were maintained by preventing a cockroach infestation in the facility. 2. Follow its Policy and Procedure (P/P), titled, "Pest Control" which indicated the facility maintained an ongoing pest control program to ensure the building was free from insects and rodents. These deficient practices resulted in the facility's kitchen being closed for use to residents on 12/10/2025, after roaches were observed in two residents' rooms (Resident 1 and Resident 2) on 11/25/2025 and 12/4/2025. These deficient practices placed 135 residents, who resided at the facility and ate food from the facility's kitchen, at risk of contracting serious diseases and allergies. A review of the facility's Concern Records dated 11/17/2025 and 12/4/2025, indicated Resident 1 saw a cockroach in her room. A review of the facility's Resident Council Departmental Response form, dated 12/9/2025, indicated Resident 2 saw a cockroach crawling on the floor in her room on 12/8/2025. A review of the Retail Food Official Inspection Report from the city, dated 12/10/2025, indicated the following cockroach sightings: 1. One live adult German cockroach on the floor near the handwashing area 2. One live adult German cockroach on the wall located next to the hand washing sink. The Retail Food Official Inspection Report indicated the facility's public health permit was suspended on 12/10/2025 and operations were to cease in the facility's kitchen. The Retail Food Official Inspection Report indicated the facility was charged with violations of the California Health and Safety Code, Section 114259.1, vermin infestation, which posed an immediate danger to public health and safety. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 79-year-old female, was initially admitted to the facility on 6/17/2024 and readmitted on 8/11/2025 with a diagnosis of chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing). A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2, a 78-year-old female, was initially admitted to the facility on 8/26/2012 and readmitted on 6/16/2024 with a diagnosis of COPD. During an interview on 12/10/2025 at 12:15 p.m., Resident 1 stated over the past couple months she observed several cockroaches in her room crawling on her bedside table and on the wall. Resident 1 stated the pest control company treated her room, but the cockroaches came back. Resident 1 stated the cockroaches were a nuisance and were dirty creatures that she did not want in her room. During an interview on 12/10/2025 at 1:30 p.m., the Environmental Health Specialist (EHS) stated during her annual inspection of the facility's kitchen on 12/3/2025 she observed two cockroaches. The EHS stated she instructed the facility to ensure the kitchen was free of pests by 12/10/2025 and failure to do so would result in closure of the facility's kitchen. The EHS stated when she returned to the facility on 12/10/2025, she observed two live cockroaches in the kitchen, which led them to close the facility's kitchen (12/10/2025). The EHS stated cockroaches carried germs on their bodies from the garbage and sewage. The EHS stated cockroaches contaminate food and surfaces as they move, especially in the kitchen and food storage areas which could cause disease in residents. During a telephone interview on 12/10/2025 the Ombudsman ([OMB] an advocate for residents of nursing homes, board and care centers, and assisted living facilities) stated on 11/25/2025 she observed a cockroach on a resident's (resident is unknown) nightstand and notified the Director of Nursing (DON) and the Social Services Director (SSD). The OMB stated on 12/4/2025 she saw several bugs which appeared to be cockroaches, one on the wall in Resident 1's room in the presence of the SSD and a second cockroach in another resident's room (Resident and room unknown) on the same hallway as Resident 1's room. During an interview on 12/11/2025 at 4 p.m., Resident 2 stated within the past week she observed a cockroach on her bedside table and notified the facility staff. Resident 2 stated cockroaches are dirty and she doesn't want them in her room. During an interview on 12/11/2025 at 4 p.m., the Maintenance/Housekeeping Director (MHD), stated the pest control company services the facility monthly and more frequently when needed. The MHD stated the pest control company treated residents' rooms for cockroaches at least three times over the past month and after each inspection and treatment, the facility received recommendations from the pest control company on what areas needed repair to prevent pests from entering the facility. The MHD stated he completed the repairs as directed by the pest control company, but he did not maintain a record of what repairs were completed and was not able to provide documented proof of those repairs. During an interview on 12/11/2025 at 4:30 p.m., the DON stated during the EHS visit on 12/3/2025, she was informed there were cockroaches in the kitchen, and they were instructed by EHS to eradicate the cockroaches by 12/10/2025 or the facility's kitchen would be closed. The DON stated on 12/10/2025, the facility's kitchen was closed for usage because during the EHS subsequent inspection on 12/10/2025 an ongoing cockroach infestation was noted. The DON stated over the past few weeks she was notified of cockroach sightings in different parts of the facility and had observed several residents' keeping food in their room, which could lead to pest in the facility. The DON stated timely repairs to any cracks and openings were important for pest prevention. The DON stated cockroaches could cause disease and allergies in residents. A review of facility's P/P titled "Pest Control" dated 5/2008, indicated, the facility shall maintain an effective pest control program to ensure that the building is kept free of insects and rodents. The facility failed to: 1. Ensure sanitary conditions were maintained by preventing a cockroach infestation in the facility. 2. Follow its P/P, titled, "Pest Control" dated 5/2008, which indicated the facility maintained an ongoing pest control program to ensure the building was free from insects and rodents. These deficient practices resulted in the facility's kitchen being closed for use to residents on 12/10/2025, after roaches were observed in two residents' rooms (Resident 1 and Resident 2) on 11/25/2025 and 12/4/2025. These deficient practices placed 135 residents, who resided at the facility and ate food from the facility's kitchen, at risk of contracting serious cdiseases and allergies. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of residents in the facility.