Facility Evaluation Report, 04/07/2025 — Pacific Gardens at University, Vallejo CA

At approximately 12:45PM, Licensing Program Analyst (LPA) Deniz arrived unannounced to conduct a 1-Year Required Visit and met with caregiver, Randy Leysa. Licensee/Administrator wasn’t present. Staff called the admin to verify if administrator was available and She wasn’t able to be present during this inspection. 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 6 non-ambulatory residents. Facility has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were 6 Residents in care.

At approximately 1:25PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 1:35PM, LPA conducted a walk-though of the facility with Caregiver, Randy Leysa. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 5 Resident bedrooms, 1 staff bedroom, 3 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Knifes and cleaning supplies were stored together under the sink in locked cabinet together (Technical Violation given).

Hot water temperatures for resident’s common bathroom sink measured 126.6 degrees F which were not found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. It poses an immediate health, safety risk to persons in care. (See LIC809-D page). Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present.