KITCHEN(S): The facility has a main kitchen for residents of the facility, and two (2) dining rooms. One (1) dining room is specifically for the Assisted Living residents of the facility, and the other dining room is for the Memory Care residents of the facility. The individual dining room areas in the memory care segment of the facility and the assisted living segment of the facility are closest to the resident bedrooms that section serves. 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 at an appropriate temperature as per the regulation. Heating devices such as stoves are inaccessible to residents as are potentially dangerous items. Continued on 809-C

COMMON AREAS: At the time of the visit, the main lounge(s) and dining room(s) were observed to be appropriately furnished, with all furniture in good condition. The entrance to the facility has a main lobby with sign in materials as well as COVID screening procedures. There is an assisted living dining room with an attached kitchenette. The facility itself is shaped in an enclosed square like design with resident rooms making up the borders while the assisted living common areas, and memory care common areas/courtyard make up the interior. There is a lounge area for residents off 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 activity materials in the common areas of the facility in good repair and operating condition. The facility maintains a grand piano, popcorn machine, and multiple rooms for resident activity. These rooms include a lounge room, salon room, and sensory room. The facility maintained a comfortable temperature in all areas 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 were fully charged and were last serviced in 2023. 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 the areas comprising the facility. 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 ramps are well-lit with sturdy hand railings/stair chair accessibility devices. This facility is one (1) story throughout and therefore there are no stairways for residents to utilize. 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 completely enclosed with auditory delayed egress exits into and out of the memory care segment of the facility. Continued on 809-C

BEDROOMS: The facility has resident bedrooms in the memory care and assisted living segments of the facility. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are 65 bedrooms that can be designated for 2 residents per bedroom to equal a total capacity of 130 residents. LPA inspected multiple rooms in both the assisted living segment and the memory care segment that houses residents. The bedroom for residents consists of 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 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: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. Continued on 809-C

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. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate isolation rooms if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. The facility maintains a COVID-19 Health Care System Mitigation Playbook from the California Department of Public Health as well as an Emergency Preparedness Informational Form and Interim Guidance for Outbreak Management in Long-Term Care and Post-Acute Care Facilities. The facility maintains an Infection Control Plan as well as an Emergency Operations Program and Plan Manual with aspects pertaining to infection control. As of 09/21/2023, this facility had an infectious disease outbreak relating to numerous cases of positive COVID-19. Residents who tested positive were isolated according to the facility’s infection control plan, and enhanced cleaning procedures were implemented in 2023.

RECORDS: The facility keeps confidential storage of personnel records and resident records on-site at the facility. Personnel records reviews were reviewed for, but not limited to 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. All staff member personnel records had the appropriate documentation with no expiration of any training. Resident records were 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/Logs, Advance Directives, Conservatorship Documentation, and Physician Orders for Life-Sustaining Treatment. Contd. 809-C

FACILITY DOCUMENTATION: There are required postings throughout the facility, including emergency exiting plans with necessary telephone numbers. The facility keeps copies of the LIC 200 Application for an RCFE, LIC 215 Applicant Information LIC 308, LIC 400 Affidavit Regarding Client/Resident Cash Resources, LIC 401 Monthly Operating Statement, LIC 402 Surety Bond, LIC 401(a) Supplemental Financial Information, LIC 403 Balance Sheet, LIC 404 Financial Information Release and Verification, LIC 500 Personnel Report, LIC 501 Personnel Record, LIC 503 Health Screening Report, LIC 610E Emergency Disaster Plan for Residential Care Facilities For the Elderly, LIC 9282 Residential Infection Control Plan, and LIC 999 Facility Sketch. The facility additionally has a Plan of Operation, Control of Property, The Job Description for Each Staff Position, Personnel Policy, In-Service Training for Staff, Facility Program Description, Rules of Discipline/Personal Rights, Admission Agreement for Residents, Sample Food Menu, Theft & Loss Policy, Neighborhood Complaint Policy, Hazard Assessment, and Job Description for the Administrator. The facility has on file a Dementia Care Plan document as well as Hospice Care Waiver. The facility had an approved inspection/test from the fire department most recently on 10/19/2023.

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