Facility Evaluation Report

Licensing Program Analysts (LPAs) Samer Haddadin and Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPAs were greeted and granted entry by Staff #4. During today’s visit, LPA met with Maria "Tisset" Domingo, Executive Director (ED).

The facility is a three-level building with an approved fire clearance of eighty-eight non-ambulatory with fifteen bedridden and are approved for a hospice waiver for sixteen. The Terrace floor is the Reminiscence Community and the first and second floors are Assisted Living. The facility currently has a census of eighty residents in care.

During today’s visit, LPA Haddadin toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in four of four resident bathrooms, and testing auditory devices on all exits . The hot water temperature measured between 108.9 and 119.9 degrees Fahrenheit and all smoke and carbon monoxide detectors were operational . The fire extinguishers were charged and serviced on October 4, 2024. The facility’s last earthquake drill was conducted on April 3, 2025 and the fire drill was conducted on April 6, 2025.

LPA Haddadin 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 residents dining for lunch in both the Reminiscence Community as well as Assisted Living. Residents do not have access to kitchen areas and sharps and knives are secured in the kitchen.