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 facility is a Continuing Care Retirement Community that consists of assisted living, memory care, independent living, and a dementia unit. The facility has waivers for Hospice and Dementia, housing both non-ambulatory and ambulatory residents.

KITCHEN(S): The facility has a main kitchen for residents of the facility in the main kitchen/dining room building. The main kitchen serves residents in the assisted living and memory care segments of the facility, as those areas have dining rooms, but no full kitchens. There is a separate kitchen in a facility restaurant building connected to the resident pool area. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in the kitchen are inaccessible to residents. Kitchen appliances were in operable condition and looked clean/in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last 7 days. Additional perishable food items were maintained on a shelf and/or an extra freezer. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation. Heating devices such as stoves are inaccessible to residents, as are sharps/other items that could constitute a danger to residents. The kitchen was clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerator were both in the appropriate temperate Fahrenheit. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food.

Continued on 809-C

OUTSIDE/LAUNDRY/MISCELLANEOUS: The facility is comprised of a large number of separate buildings for multiple uses, including a fitness center, pool with jacuzzi, resident clinic, mailroom, thrift store, and resident convenience store. There is a main entrance road into the facility and an administrative entrance area for visitors. The facility has walls of concrete surrounding the backyard area of the memory care portion of the facility, with electronic combination delayed egress entrances/exits. The facility has an outdoor patio area for residents outside of the resident restaurant next to the pool area. The pool/body of water and jacuzzi comply with all safety instructions per the regulations. Currently the pool is undergoing construction so there are no bodies of water on the facility premises. Outdoor activity spaces and the dining patio for residents are equipped with furniture for resident use. Electronic devices are in place to monitor exits of the memory care building in the facility, if exiting presents a hazard to any resident. All outdoor areas with stairways, inclines, ramps, or open porches have accessibility ramps for residents, are well-lit, and have hand railings/grab bars. This is a facility with over 16 residents, therefore there are multiple designated laundry rooms where cleaning products are stored, which are kept locked. Continued on 809-C

BEDROOMS: The facility has resident bedrooms in the memory care, assisted living, and independent living segments/buildings. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are hundreds of designated resident rooms in the facility, with the LPA inspecting multiple rooms in each building that houses residents. The bedrooms for residents consists of a restroom in the room, a closet area for storage, a bed, and room for a couch and/or television with furniture. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assisting device such as a wheelchair or a walker. Each room has at the least a chair, night stand, chest of drawers, and sufficient lighting. Each resident bedroom in the independent living segment of the facility is furnished with a smoke alarm/fire alarm system, emergency call system, and appliances for the residents.

RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are non-private restrooms in the common areas of the facility as well as private restrooms in the resident’s bedrooms in specific buildings of the facility. All restrooms inspected by the LPA had assisting equipment for residents including grab bars and/or non-skid surfaces. The bathrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit. There are an adequate number of toilets and tubs/showers per resident in the facility. Night-lights are installed in the hallways outside of the common area restrooms.

INFECTION CONTROL: Upon entry to each building, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. Continued on 809-C

This required annual 1-year facility site inspection visit will need a continuation visit to conclude the aspects of the visit constrained by time limitations. These aspects include Facility Records compromising Staff member files for LIC 501 personnel records, LIC 503 health assessments with Tuberculosis (TB) test results, Personnel Action Notice, Job Description with date of employment, LIC 9052 Employee Rights, LIC 508 criminal record Statements, criminal record clearances, first aid/CPR certification that is not expired, and the appropriate training. Additionally, Resident records need to be reviewed for LIC 603 Pre-Admission/Placement appraisals, LIC 602 Physicians Reports, Consent Forms, Personal Rights for Residents, LIC 601 Emergency Information, LIC605A Release of Medical Information, PRN Authorization, Needs and Services Plan (ANS), Resident Assessments, Mini-Mental State Exam (MMSE) for residents with dementia, Self-management of medications if applicable, Medication Orders, Medication Logs, Advance Directives, Conservatorship Documentation, and Physician Orders for Life-Sustaining Treatment (POLST). Facility medications also need to be audited for a locked centralized storage area for resident medications as well as the Centrally Stored Medication and Destruction Record for residents.

No deficiencies cited. Exit interview conducted. A copy of the report was issued.