This facility is licensed to serve eighty-one (81) residents, age 59 and older, of whom eight (8) may be bedridden on the first floor only. The facility may retain no more than twenty (20) hospice residents. At the time of the inspection, thirteen (13) residents were receiving hospice services.

The facility provides care to both Assisted Living and Memory Care residents. At the time of the inspection, the facility census was sixty-one (61) residents.

Physical Plant and Environmental Safety:

LPA toured the Assisted Living and Memory Care (Evergreen) areas of the community. A total of twelve (12) resident rooms 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. Water temperatures in public restrooms located on the first and second floors were also tested and measured within the required regulatory range of 105°F to 120°F. Public 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.

LPA observed the facility to be clean, odor-free, and maintained in good repair. Interior and exterior passageways were free of obstructions and provided safe ingress and egress for residents. Outdoor areas were furnished with appropriate seating and shade, allowing residents access to safe outdoor recreational space. (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 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. 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. 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).

Planned Activities:

LPA observed residents participating in a staff-led group exercise class. The July 2026 activity calendar was posted and included a variety of recreational activities, fitness programs, social events, and scheduled community outings. LPA observed adequate outdoor recreational space for residents, providing opportunities for outdoor activities, relaxation, and social interaction.

Amenities:

LPA observed that the community offers a variety of amenities for resident use, including activity rooms, an on-site beauty salon, and outdoor patio areas with beautiful scenery. These amenities provide residents with opportunities for recreation, social engagement, personal care, and enjoyment of the outdoor environment. 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.

(continued on 809C)

Seven (7) 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.

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 Daisy Hernandez was valid through February 7, 2027.

Disaster Preparedness

LPA received copies of the facility's Telgian Fire Sprinkler System Inspection/Test Reports, including the required comprehensive inspection report dated June 22, 2026. Facility records reflected that the last fire and earthquake drill was conducted on May 27, 2026. Documentation of emergency drills was 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.

LPA reviewed the facility's current liability insurance policy and verified that coverage is in effect through May 1, 2027.

An exit interview was conducted with Daisy Hernandez, Administrator. During the inspection, the facility was observed to be following Title 22, Division 6 regulations. No deficiencies were cited at this time. A copy of the report was provided.