Facility Evaluation Report

On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and LPA Kimberly Lyman made an unannounced visit to conduct a required annual. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit.

The facility is a three level building with an approved fire clearance of nine ambulatory; eighty-eight non-ambulatory residents of which fifteen are approved for hospice. The facility currently has a census of 72 residents in care.

LPAs toured the facility and inspected the physical plant, including but not limited to testing hot water temperature in the bathrooms. The hot water temperature measured 108.6 and 117.6 degrees Fahrenheit. The facility uses Cal Building Systems for smoke directors and fire sprinkler service and the last inspection was conducted on 03/18/2025. The facility conducted an emergency drill on 10/14/2025. LPAs inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPAs observed 3 cases of water in the underground parking structure for emergencies.

LPAs reviewed 9 resident files, Residents 3, 6 and 7 did not have updated LIC 602 Physicians Report.

LPAs reviewed 6 staff files and no staff had CPR or first aid training. LPAs observed staff did not have the annual training that includes 4 hours of training on the following topics: postural support, restricted health conditions and hospice care LPAs observed unsecured laundry room in Memory Care that contained an unsecured cabinet with toxins. LPAs did not observe PUB 475 in the entryway of the facility. LPAs observed Resident 3 who is listed as bedridden in a room that is not cleared for bedridden resident.