Facility Evaluation Report

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to Business Office Manager Michelle Castillo. The Residential Care for Elderly (RCFE) facility serves residents ages 60 and over. There is a Memory Care Unit for cognitively impaired residents.

Infection Control: The Infection Control Plan was reviewed. The facility has sufficient supply of Personal Protective Equipment (PPEs).

Operational Requirements: The facility has an approved fire clearance for 104 ambulatory and 116 non-ambulatory residents, of which 104 residents may be bedridden. A hospice waiver for 25 residents is approved. Facility does not handle resident monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 2/1/2026.

Physical Plant/Environment Safety: The facility is a 2-story building consisting of 119 resident rooms, Memory Care Unit, 2 activity rooms with fireplaces, library, game room, beauty salon, private dining room, dining room, shower rooms on the 1 st and 2 nd floors, outdoor courtyards with shaded areas, employee lounge, and offices. Resident rooms have required furniture, bedding, linens, and lighting. The majority of the resident rooms inspected had beds without mattress pads. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. Cleaning supplies and toxic substances are inaccessible to residents. The signal system was tested and is operational. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has charged fire extinguishers. Rooms 130 & 133 do not have No Smoking/Oxygen-In Use signs. The Memory Care Unit had cleanliness issues and deferred maintenance. The last fire inspection was conducted on 4/30/25 by Pasadena Fire Department.