Facility Evaluation Report

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced One (1) year Required visit at this facility. LPA met with Executive Director Carlos Lara and explained the reason for the visit.

At 9:23 AM, with the assistance of the Executive Director, LPA toured the facility inside and out and the following was observed:

The facility is a four (4) storey building fire cleared for 155 non-ambulatory residents, four (4) of which may be bedridden and has hospice waiver for twenty (20) residents. The facility had submitted and approved Mitigation and Infection Control plan. The facility's smoke alarms are hard wired and interconnected. Last testing, which includes the sprinklers, fire door, alarms and exit light was completed on 12/12/24. Fire/earthquake and emergency evacuation drill is conducted on monthly basis for different shift and the last one was conducted ton 08/13/25. The fire extinguishers throughout the facility hallways are on all four (4) floors, all extinguishers were last serviced on 05/20/25.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility and properly stored. Residents do not have access to the kitchen. Listing for residents that require a special diet is posted on the kitchen wall. There were no pesticides or poisons observed near any food areas. Kitchen/food service staff observed with gloves and proper hair cover.

Bedrooms: Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Emergency push button was tested for proper function.