Facility Evaluation Report

On 04/14/25, at approximately 9:30 a.m., LPA Evelin Rios conducted an unannounced annual continuation case management visit. Upon arrival, LPA signed in at reception as requested by the security guard. LPA was then greeted by Supervisor Psychiatric Social Worker Seema Misra, who escorted LPA to the Administrator's office. There, LPA met with Administrator Edina Lemus and explained the purpose of the visit.

During the initial annual visit on 12/16/24, the facility had completed the required corrective actions noted in its fire and life safety inspection from 06/10/24. As part of today’s assessment, LPA reviewed the facility’s fire and life safety re-inspection report dated 02/19/25. The inspection confirmed the facility had passed. Additionally, LPA reviewed the annual inspection report conducted by the County of Los Angeles Fire Department, which showed no deficiencies. LPA also examined the facility’s infection control plan, fire drill records, and after-action reports for both the "Shake Out" drill and the reception of West Los Angeles RCFE residents affected by the Palisades Fire.

From approximately 11:06 a.m. to 12:00 p.m., LPA, assisted by Staff Services Manager I, Annette Barrera, and Nurse Instructor Takira Florence, reviewed seven (07) staff records to ensure compliance with licensing requirements and up-to-date training. From 1:00 p.m. to 3:30 p.m., LPA reviewed six (06) resident records for completeness and adherence to licensing standards. No issues were observed during the review.

During the initial annual visit on 12/16/24, LPA toured three (03) shared rooms . On today’s visit, LPA toured two (02) additional shared rooms. All rooms were appropriately furnished and had sufficient lighting . (Continue to LIC809-C)