Facility Evaluation Report

License Program Analyst (LPA) Hansen arrived unannounced to conduct annual inspection visit of the facility. LPA was welcomed by CEO Kyle Ruth-Islas, Administrator Elena Davidenko arrived shortly after. Facility’s fire clearance granted by Southern Marin Fire Department on 6/6/2025 for 150 residents 35 nonambulatory, 12 of which in new memory care unit, also cleared for 2 exterior areas of memory care unit, each with egress doors and Noc Box for fire department. Facility approved for Hospice waiver of 8. There is a total of 112 residents, 13 of which have dementia diagnosis. There are 3 residents currently on Hospice.

LPA toured the facility on 9/23/2025 at 10:30 AM with Administrator, CEO and Will Orellana,facility director; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on 1/24/2025 at the time of the visit. Facility hallway smoke detectors are hard wired and sound directly to fire station. Smoke detectors, carbon monoxide, and fire sprinklers are inspected, and inspection records are current, with the last being conducted on 8/4/2025. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 104.3 degrees F and 124.8 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 5 of 12 resident’s faucet bathrooms while touring facility. Although LPA was informed plumber was on site working on water heaters and when reinspected most were in range. Will recheck at return visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit, covered, labeled, and dated. LPA toured kitchen area and learned that there are provisions made for individuals/residents with special dietary needs. Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in locked housekeeping rooms. There was a supply of cleaners, hygiene products and paper products available for residents. Continue on LIC 809-C