Facility Evaluation Report

At approximately 8:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year Visit and met with Business Office Director, Ditter Vazquez and Resident Care Coordinator, Mariana Ramirez . Executive Director, Kimberly Humphrey, arrived during visit at approximately 9:50AM. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 70 non-ambulatory residents, of which 20 residents can be bedridden. Facility has an approved hospice waiver for 16 individuals. Facility is currently on a Non-Compliance Plan. Upon arrival, LPA was informed that there were 55 residents in care and 20 staff members on-site.

At approximately 9:25AM, LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Executive Director and observed the following: Facility is a 2 story building. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Facility fire extinguishers were last inspected March 2025. During walk-through, LPA observed the following deficiencies: 4 of 8 resident sinks were found to be out of compliance with Title 22 regulations of 105 to 120 degrees Fahrenheit, measuring at 120.7F, 120.2F, 121.4F, and 122.1F (deficiency cited, regulation 87303(e)(2)), 5 instances of unlabelled and undated foods were observed (deficiency cited, regulation 87555(a)), and facility did not have adequate emergency water supply in the event facility had to shelter in place for at least 72 hours (deficiency cited, Health and Safety Code, 1569.695(a)(2)).