The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE) Continuing Care Retirement Community (CCRC). This facility is approved for a maximum capacity of three hundred and sixty (360) residents. Of these residents, one hundred and forty-four (144) may be non-ambulatory. The facility has an approved hospice care waiver for six (6) residents in care. The facility is approved for delayed egress entry and exit in the memory care unit of the facility.

The LPA inspected the food service areas in the facility including two (2) main kitchens for residents of the facility in the main dining room building. There are also individual kitchen areas in the memory care unit of the facility and the assisted living area of the facility. The facility additionally has a kitchen in the “Grill” building which serves as a more casual dining experience for residents. LPA observed that knives/sharp instruments are stored in locked drawers inaccessible to residents. All appliances were in operable condition and looked clean/in good repair. Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly. Food utensils, dishes, glasses, etc. are clean and in good repair with no cracks or chips. Furniture is room/resident appropriate, clean and in good repair. All rooms are appropriately furnished for their intended use such as bedrooms, dining rooms, kitchens, living rooms, etc. Hot water temperature is maintained between 105-120 degrees Fahrenheit as per Community Care Licensing (CCL) Title 22 regulations. Outdoor activity spaces have shaded areas and furnished for outdoor use. Each resident has an adult bed with a mattress, pad, bedsprings, and pillow, which are clean and in good repair. Each bed is fitted with sheets, pillowcase, blankets, and bedspread that are clean and in good repair. Continued on 809-C

At the time of the visit, all common areas/interior rooms of the facility were observed to be appropriately furnished, with all furniture in good condition. There are multiple fireplaces on the premises, which were all covered and inaccessible to residents. The facility contains common areas such as a billiard room, auditorium, and life enrichment center building that includes arts/crafts rooms as well as exercise/gym rooms for residents. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguishers were fully charged and are serviced annually. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity materials in the common areas of the facility in good repair and operating condition. The facility maintained a comfortable temperature in all areas inspected. There is appropriate lighting in all the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all changes in incline are well lit with sturdy hand railings/stair chair accessibility devices. All window screens were in good repair. Continued on 809-C

The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms in the facility were sufficiently stocked with soap, paper towels, required postings, and clean trashcans with closed lids. Towels and washcloths are not shared by residents in the facility. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per Title 22 regulations between 105-120 degrees Fahrenheit. There are an adequate number of toilets per residents in the facility. Nightlights are installed as observed by LPA. All toilets and hand washing areas are maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences are available accommodate any physically handicapped residents who need such items. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Each resident bedroom has a bed, nightstands, and lights and nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms can store or has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. Continued on 809-C

An emergency exiting plan and emergency phone numbers are posted in an appropriate place. A current disaster and mass casualty plan maintained at the facility. The facility’s policies and procedures as it pertains to infection control are adequate. First-aid supplies, which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual, are maintained. Administrator’s records, employees and resident records are maintained at the facility and available for review by the LPA as employees are hired and residents accepted into the facility. The facility complies with CCL standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Admission agreements and needs and services (ANS) plan are maintained for each resident and/or their authorized representative. Resident records are maintained on the facility premises in a secured area. Centrally stored medications are locked in secure locked cabinet(s) inaccessible to residents. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. LPA audited the medications for residents and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility. The facility administrator meets the qualifications as specified in Title 22 regulations. Administrator has a current RCFE administrators’ certificate with an expiration date of 12/03/2025. There are required postings throughout the facility, including emergency exit plans with necessary telephone numbers. Provider Information Notices are available and able to be presented to Staff, residents, visitors, and accessible to LPA upon request during the inspection process.

Exit interview conducted by LPA. Copy of this report provided to the facility.