Facility Evaluation Report

On 04/10/2026 at 10:00 AM, an office visit was held by the El Segundo Adult and Senior Care Regional Office. During the meeting the following people were present: Janae Hammond (Regional Manager), Ulysses Coronel (Licensing Program Manager), Regina Cloyd (Licensing Program Analyst), Brittany Kavanaugh (Regional Director), and Linda Poythress (Executive Director) to address repeated fire clearance violation.

On 09/24/25, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a case management visit to the facility. During the visit, LPA requested a resident roster and list of residents who were bedridden. Upon review of the roster, LPA observed Resident was residing on floor two and is bedridden. The current facility fire clearance indicates that floor on is cleared for bedridden residents. Floor two is cleared for non-ambulatory residents.

On 03/12/26, Licensing Program Analyst (LPA) Regina Cloyd conducted an annual During record review, Resident #1 (R1) and Resident #2’s (R2) physician report revealed both residents as bedridden due to physical and mental condition. The facility's fire inspection (07/03/2024) special conditions states bedridden residents are only permitted to be on the first floor. Review of Resident Roster (03/11/2026) revealed R1 and R2 in rooms on the second floor.

A discussion was had about the past visits, the significance of adhering to the fire clearance, Executive Director monitoring change of conditions (ambulatory status), an ambulatory audit conducted by the facility, and the Regional Office following up with the Fire Department to clarify the facility current Fire Inspection Report (STD 850) on file. An exit interview was conducted and a copy of this report was provided to the Regional Director Brittany Kavanaugh.