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) comprised of 8 separate buildings, including a memory care resident building, assisted living resident building, fitness & aquatic center, 4 independent living resident buildings, and a building combining a library, patio room, main dining room, main lounge, and the administration offices. The facility also houses a wellness clinic within the memory care building and a corner store within one of the independent living buildings. The facility is licensed for a maximum 266 residents who are 60 years of age or older. 147 of the residents may be non-ambulatory, 91 ambulatory, and 28 bedridden. The facility has both Dementia Waiver and a Hospice Waiver for 20 residents. At the time of the annual inspection, a COVID-19 infectious disease outbreak that began 07/25/2024 had four (4) residents and no staff testing positive, which was reported to the Licensing Agency and Public Health Agency.

KITCHEN(S): The facility has a main kitchen for residents of the facility in the main dining room building. There are also individual kitchen areas in the memory care segment of the facility and the assisted living segment of the facility. 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 a week or more. 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. Continued on 809-C

COMMON AREAS: At the time of the visit, the main lounge and dining room were observed to be appropriately furnished, with all furniture in good condition. There is a lounge area for residents off of the main dining room and main lounge that is appropriately furnished, with all furniture being in good condition. There are multiple fireplaces on the premises, which were all covered and inaccessible. There are pianos in the common areas of the facility in good repair and operating condition. The facility maintained a comfortable temperature in all 8 separate buildings inspected. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit in each of the buildings inspected. The fire extinguishers in all buildings inspected by LPA were fully charged and were last serviced annually. The LPA observed required postings throughout all common spaces including Resident Personal Rights and Resident Council Rights. There are activity supplies and equipment, including reading materials for the residents in all common areas inspected. All window screens were in good repair in all of the buildings comprising the facility. There is appropriate lighting in all of the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all stairways are well-lit with sturdy hand railings/stair chair accessibility devices. As the facility has more than 16 residents and is multiple stories, there is a signal system in place which was functional at the time of the inspection by the LPA.

OUTSIDE/LAUNDRY/MISCELLANEOUS: The facility is comprised of 8 separate buildings for multiple uses, with garages for independent living residents. There are multiple story buildings at the facility, with evacuation stair chairs at each stairwell. There is a main entrance road into the facility and an Arrival Plaza Kiosk. The facility has walls of concrete surrounding the entrances and exit locations of the facility for resident protection/privacy. The facility has a new outdoor patio area for residents outside of the main dining room and main lounge building. Outdoor activity spaces and the dining patio for residents are equipped with furniture for resident use. The memory care building/segment of the facility has delayed egress entrances/exits. Auditory 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. 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 differ between shared units with 2 beds per room, and individual units with 1 bed per room. 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 assistive device such as a wheelchair or a walker. Each room has at the least a chair, nightstand, 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: LPA observed facility restrooms sanitized and in operating condition. 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 including independent living. 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. 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. Continued on 809-C

RECORDS/MEDICATIONS: LPA reviewed 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. The administrator of the facility has an active Residential Care Facility for the Elderly (RCFE) administrator certificate that expires on 05/18/2025. Additionally, Resident records 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 were audited by LPA for a locked centralized storage area for resident medications as well as the Centrally Stored Medication and Destruction Record for residents.

FACILITY DOCUMENTATION: LPA observed required postings throughout the facility. Provider Information Notices are easily accessible and presented to LPA upon request during inspection process.

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