This facility is licensed to serve fourteen (14) ambulatory residents and five hundred and sixty (560) non-ambulatory residents, age 60 and over. The facility may retain no more than fifteen (15) hospice residents. At the time of the inspection, there was (1) resident receiving hospice services.

The facility provides care to assisted living residents in four (4) different areas of the community with the following census:

· Pinecrest – eighteen (20) residents

· Cedar Court – eleven (10) residents

· Maple Court/Birch Court – thirty-one (59) residents

· Southwood Lodge Memory Care – twenty-four (21) residents--Southwood Lodge Memory Care is approved for delayed egress.

The total community census for memory care and assisted living at the time of the inspection was one hundred and twenty (120) residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool during today's inspection and observed the following:

(continued on 809C)

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

LPA received copies of the facility's Wet Pipe Sprinkler Inspection/Test Reports, including the required comprehensive inspection reports for both the Assisted Living and Southwood Lodge Memory Care wings. Facility records reflected that the last fire and earthquake drill was conducted on June 12, 2026. Documentation of emergency drills were available for LPA's review. LPA observed that the facility's LIC 610D, Emergency Disaster Plan, was in the process of being updated. Emergency disaster supplies, including potable water, nonperishable food, flashlights, batteries, and first aid supplies, were observed and appeared sufficient to meet emergency preparedness requirements.

Personnel Records & Training

Five (5) staff files were reviewed and included criminal record clearances, CPR/First Aid, required training and TB screenings. Administrator Certificate for Keith Kasin was valid through August 10, 2026.

An exit interview was conducted with Desiree Eudave, Sr. Director of Residential Care. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided.

The community is centrally located within the City of La Verne and is considered a Continuing Care Retirement Community (CCRC). LPA toured the Memory Care unit (Southwood Lodge) and the Assisted Living areas, including Maple Court, Birch Court, and Cedar Court. A total of ten (10) resident bedrooms were inspected. All resident rooms contained the required furniture, linens, and adequate lighting. Water temperatures in resident grooming and bathing areas measured between 105°F and 120°F. Restrooms displayed postings encouraging proper handwashing, and resident bathrooms were equipped with grab bars adjacent to toilets and inside showers. Disinfectants, cleaning supplies, poisons, and other hazardous materials were observed to be secured and inaccessible to residents. Carbon monoxide detectors and smoke alarms were observed in resident bedrooms and hallways. LPA also observed evacuation chairs positioned in stairwells for emergency use.

Food Service:

LPA toured both dining areas and the kitchens that serve the Assisted Living and Memory Care residents. LPA observed proper food storage, food preparation, and food handling practices throughout both kitchen areas. No chemicals, cleaning supplies, or other hazardous substances were observed in food preparation or food storage areas. LPA discussed with kitchen staff the process for monitoring and providing meals to residents with physician-ordered special diets. Kitchen staff explained that resident dietary needs and special meal plans are tracked through the community's Dine OS system, which assists staff in ensuring meals meet nutritional needs. Staff further stated that the community employs a certified nutritionist who oversees menu planning to ensure meals meet residents' nutritional needs. LPA observed the community’s daily and weekly menus, which were posted and available for resident review. Food menus were readily available throughout the community, and printed copies are available for residents upon request. The facility maintained at least a one-week supply of nonperishable food and a minimum two-day supply of perishable food. Soaps, detergents, and cleaning compounds were stored separately from food supplies. Freezers and refrigerators were clean and maintained at appropriate temperatures. Freezers measured approximately 0°F (-17.7°C), and refrigerators were maintained at or below 40°F (4.4°C).

LPA observed several residents participating in a staff-led seated exercise program. A July 2026 activity calendar was posted and included a variety of recreational activities and scheduled community outings. LPA observed adequate outdoor recreational space for residents in both the Assisted Living and Memory Care areas. However, a section of the Southwood Lodge Memory Care outdoor patio lacked adequate shade, and portions of the patio were observed to be in disrepair. A citation will be issued.

Amenities:

LPA observed that the community offers a variety of amenities for resident use, including a movie theater, an enclosed swimming pool area, a fully equipped fitness gym, and an on-site beauty salon. These amenities provide residents with opportunities for recreation, exercise, personal care, and social engagement. LPA observed the amenities to be clean, well-maintained, and available for resident use.

Residents Council Meeting:

LPA reviewed documentation of the facility's monthly Resident Council meetings. The meetings provide residents with an opportunity to voice concerns, offer suggestions, discuss community matters, and participate in decisions affecting their living environment. Documentation reflected the facility's ongoing efforts to encourage resident participation and promote resident rights within the community.

Resident Rights/Information:

LPA observed the required postings displayed throughout the facility's common areas, including the Complaint Poster (PUB 475), Personal Rights, and the Nondiscrimination Notice. Internet access was also available for resident use.

Health-Related Services & Records

Ten (10) resident files were reviewed. Files contained current required documentation, including Admission Agreements, signed consents, Needs and Services Plans, Physician's Reports documenting TB results and ambulatory status, and signed Resident Rights acknowledgments. Residents' medications were reviewed. Medications were observed to be centrally stored in the facility's medication room in locked medication cabinets, locked medication carts, and a locked medication refrigerator. All medications observed were maintained in a secure manner and inaccessible to residents.

(continued on 809C)