Facility Evaluation Report

On 7/2/2025 at 9:30AM, Licensing Program Analysts (LPAs) G. Luk and A. Christy arrived unannounced to conduct a Required - 1 Year inspection. LPAs met with Executive Director, Chelsea Espinoza and explained the reason for the visit.

LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in medication carts located in med rooms. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 3/17/2025. There were evacuation chairs in each stairwells.

One week of nonperishable and 2-day of perishable food supplies were available. Facility orders food twice a week. Freezer’s temperature was registered at -2 degree F while the refrigerator’s temperature was recorded at 32 degrees F. Hot water temperature was measured at 111.1 degrees F in a resident's bathroom. Grab bars for each toilet and shower were installed. Non-skid materials were observed in showers. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Last fire drill was conducted on 5/20/2025.

LPAs reviewed 5 residents and 5 staff records during inspection. All residents and staff records were complete. All staff are fingerprint cleared and associated to the facility. LPAs reviewed a sample of resident's medication and medication administration records. LPAs interviewed some staff and residents during inspection.