Facility Evaluation Report

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA met with Alisa Dean, Executive Director, and the reason for the visit was explained.

The facility is licensed to serve adults age range 60 and over; approved for 150 non-ambulatory of which 20 can be bedridden; Hospice waiver approved for 20 residents. The facility is operating within the scope of its license. The facility is in a residential area of Temple City and consists of (89) resident rooms with bathroom included in each room, main entry lobby/lounge, (5) administrative office, medication room, kitchen, (2) dining rooms, (2) patios/courtyards, movie theater room, activities room, (6) staff/visitor restrooms, garden room/TV room, beauty parlor, staff break room, (2) maintenance/housekeeping storage rooms, laundry room, record room and parking lot.

During today’s visit, LPA toured the physical plant. Facility was observed clean throughout. Hallways, walkways and exits are kept free of debris and obstructions. LPA inspected the common areas and randomly checked (10) resident rooms. Resident rooms have the required furniture, bedding, closet space and lighting. Bathrooms were observed clean and sanitary. Water temperature was tested in each bathroom and measured between 105.3 – 115.5 degrees F. which is within compliance range. Bathrooms have anti-slip mats and grab bars; however, shower side grab bar in room #143 and shower grab bar above faucet in room #112 are loose. Grabs bars were observed not properly bolted to the wall in both rooms. Call buttons in resident rooms were tested and working properly. Common areas have sufficient seating, and furniture is in good repair. There are no swimming pools or other bodies of water on the premises. Fire extinguishers were observed throughout the facility and are kept charged and operational. Fire extinguishers were last serviced on 8/21/2025. Laundry room is clean and appliances are operational. LPA also conducted interviews with (9) residents during the tour.

Due to time constraints, LPA Cota will return to complete the annual inspection. Deficiency noted during today’s visit and a Civil Penalty was assessed for $250 for Repeat Violation. Exit interview was conducted with Alisa Dean, Executive Director, and a copy of this report, 809-D, Appeal Rights and LIC 421FC was provided.