Inspection Report
Annual Inspection
Census: 48
Capacity: 70
Deficiencies: 0
Jul 3, 2025
Visit Reason
The visit was an unannounced required annual inspection conducted by Licensing Program Analyst Brandon Lopez to evaluate compliance with licensing requirements at the facility.
Findings
The inspection found the facility to be in compliance with all applicable regulations. No deficiencies were cited. The facility was observed to be clean, safe, and well-maintained with operational safety equipment and proper resident accommodations.
Report Facts
Licensed capacity: 70
Current census: 48
Fire extinguisher service date: Oct 8, 2024
Last fire inspection date: Mar 21, 2025
Last emergency disaster drill date: May 8, 2025
Hot water temperature range: 108-114
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Acosta Louer | Executive Director | Assisted with the inspection and was present during exit interview |
| Brandon Lopez | Licensing Program Analyst | Conducted the inspection visit |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Original Licensing
Census: 48
Capacity: 70
Deficiencies: 0
Jul 23, 2024
Visit Reason
The visit was a subsequent pre-licensing continuation visit to follow up on issues identified during the initial pre-licensing visit on July 18, 2024.
Findings
The previously identified issues regarding water temperature, posting of admission agreements and licensing reports, completion of the Emergency Disaster Plan, and hanging the Administrator's Certificate were all addressed and corrected. The pre-licensing is now complete, pending final review and approval.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the announced subsequent pre-licensing continuation visit. |
| Sandra Acosta-Louer | Executive Director | Met with Licensing Program Analyst during the visit. |
| Brent Broadhurst | Administrator | Named as facility administrator. |
| Lourdes Montoya | Licensing Program Manager | Responsible for final review and approval of the license. |
Inspection Report
Original Licensing
Census: 47
Capacity: 70
Deficiencies: 4
Jul 18, 2024
Visit Reason
The visit was a pre-licensing inspection conducted for a change of ownership and initial application to operate a Residential Facility for the Elderly with a capacity of 70 residents.
Findings
The facility was inspected for structure, safety systems, cleanliness, and compliance with licensing requirements. Several items were noted for correction prior to licensure, including water temperature in resident bathrooms, posting of admission agreements and licensing reports, completion of emergency disaster plan documentation, and hanging the Administrator's Certificate.
Deficiencies (4)
| Description |
|---|
| Water temperature in two resident bathrooms exceeded the acceptable range, measuring 123.4 and 122.9 degrees Fahrenheit. |
| Facility did not post a copy of the admission agreement, licensing reports, or resident council meeting notes or maintain a notice of their availability for the public. |
| Page 2 of the Emergency Disaster Plan (LIC610E) was missing and needed to be completed and posted. |
| Administrator's Certificate was not hung and needed to be displayed. |
Report Facts
Facility capacity: 70
Current census: 47
Water temperature: 123.4
Water temperature: 122.9
Fire clearance approval: 62
Fire clearance approval: 8
Emergency food/water supply expiration year: 2031
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the pre-licensing inspection visit |
| Sandra Acosta-Louer | Executive Director | Facility representative present during the inspection and exit interview |
| Lourdes Montoya | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Brent Broadhurst | Administrator/Director | Facility Administrator/Director named in the report |
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