Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA met with Asst. Administrator Martha Rosas and explained the purpose of the visit. Afterwards, Executive Director Pam Ogot arrived and assisted LPA with the inspection. Facility is licensed for 45 non-ambulatory, maximum of (8) hospice residents and (4) bedridden residents ages 60 and over. Currently, there are (45) residents in the facility who are 60 years and older, of which (1) is bedridden and (4) are receiving hospice care. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has an Infection Control Plan. Staff are adhering to infection control requirements. Emergency and disaster plan was completed and up to date. Infection control practices and Personal Protective Equipment (PPEs) were maintained.

Operational Requirements: The Infection Control Plan has been added to the Plan. Facility accepts and retains residents with dementia. Approved Dementia Care Plan is in their plan of operation. There is no separate memory care unit inside the facility. Facility is approved for (8) hospice residents. Liability Insurance is in place . Surety bond in the amount of $10,000.00 is current. Fire drill was last conducted on 03/20/2025.

Physical Plant/Environment Safety: At 10:15am, LPA along with Asst. Administrator toured the facility. The facility is a 2 story building located in a residential community. The grounds in the facility are well landscaped and have a leveled walkway to the entrance of the building. The facility consists of: First floor: Lobby, Administrative offices, Medication room, Laundry room, (1) Elevator, Large Dining area, Kitchen, Pantry, Activity room/patio, Storage room, Patio by the main entrance, and resident rooms. Second floor: Resident bedrooms, Beauty shop, Activity room and a community shower. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility is equipped with cameras in the common areas. E ach residents' room has their own restroom. In some of the observed bathrooms, there were no grab bars and non-skid mats. The exit points of the building, including the residents' living units, had no signal systems. Cleaning supplies and toxic substances are inaccessible to residents. At 10:30am, LPA tested hot water tempera ture in six (6) random resident rooms (Rooms #5, #6, #9, #209, #212, #216) in the first & second floors and t he water temperature readings were below the required 105 - 120 degrees Fahrenheit. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operational and compliant. The fire extinguishers were observed throughout the facility and are fully charged. Pull Fire alarm system observed and connected to the City of Monrovia Fire Department. Delayed egress devices in place. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. *****CONTINUED ON LIC809-C*****