Facility Evaluation Report

Licensing Program Analysts (LPAs) Angela Barutyan and Emily Peraldi arrived at the facility unannounced to conduct a Case Management - Annual Continuation visit at 12:45PM continuing the inspection that began on 06/13/2025. LPAs met with Executive Director (ED) Allison Marty and explained the purpose of the visit.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: Beginning at 12:55PM, the LPAs reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 07/08/2025. The community’s smoke detectors and carbon monoxide detectors are hard wired and were last tested on 05/19/2025 by Hiller Fire and approved by the Los Angeles Fire Department.

RECORD REVIEW: Beginning at 01:55PM, ten (10) resident and ten (10) staff records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, personal rights, and first aid/CPR training. All resident files reviewed were complete and were observed to be in compliance. Four (4) out of seven (7) care staff files were missing valid first aid certification by qualified agencies. During today’s visit, LPAs obtained a copy of the facility’s liability insurance.

Due to time constraints, the LPA will return at a later date to continue the inspection.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct the deficiency may result in civil penalties.

Exit interview conducted. Appeal rights and a copy of the report was provided.