Facility Evaluation Report

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced required annual inspection. LPA, met with Kay Cano, Executive Director, and the reason for the visit was explained. The facility is licensed to serve 245 non-ambulatory residents ages 60 and over, of which 30 may be bedridden on 1st and 2nd floors, there is an approved delayed egress and Hospice waiver for 35. There are currently 30 residents on hospice.

The facility is an 8-story building located in Pasadena.

During today's visit, LPA conducted the following:

Review was conducted for (10) staff files. Staff files contain criminal record clearance, current First-Aid training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training.

Review was conducted for (20) resident files. Resident files have the following documents in place: Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report.

Tour of the medication room. Medication is centrally stored in a medication room. Fifteen (15) residents' medication was inspected and found to be administered and documented accordingly, per physician's orders.

Interviews were conducted with (10) staff.

Infection Control and Emergency Preparedness plan are in place and up to date. Last safety drill was conducted on 10/22/2025 and 12/10/25.

No deficiencies were noted during this visit. Due to time constraints, an annual continuation will be conducted at a later time. Exit interview was conducted with Kay Cano, Executive Director, and a copy of this report was provided.