At 9:38 AM, the LPA initiated a walk-through of the facility, accompanied by a staff member.

LPA inspected six (6) random resident rooms in the Assisted Living and five (5) random resident rooms in the Memory Care, and found them clean, well-lit, and equipped with the required furniture. All exit doors in the rooms had auditory alarms for notification. Emergency pull cords were observed working next to the resident beds. “Oxygen in use” signs were posted outside the resident’s room using oxygen. LPA inspected private bathroom in all the rooms. The bathrooms contained soap, grab bars, towels, a trash can, and non-slip flooring. The hot water temperature at the sink faucet was measured between the range of 112.8°F to 119.5°F.

LPA inspected the common resident bathroom with shower and found it clean, sanitary, and in good working condition. It contained soap, grab bars, a trash can, non-slip flooring, curtain, shower bench, and a shower chair.

LPA inspected the laundry room and observed two (2) sets of industrial size washer and dryer, and on (1) set of a residential washer and dryer in working condition.

LPA inspected the kitchen and found it clean. LPA inspected the refrigerator, freezer, and pantry room and observed enough supplies of fresh perishable food for (2) days and nonperishable staples for (7) days.

LPA inspected the dining room and lounge area and found it clean, with all the furniture in good repair. LPA observed residents participating in the painting activity in the lounge area.

Continued on LIC 809-C

LPA toured the patio and yard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. These areas had patio tables, chairs, and umbrellas for residents’ use. Delayed egress was observed on all exit doors.

LPA reviewed (5) staff personnel records and (5) resident records. The LPA observed that 5 of 5 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 5 of 5 staff members were associated with the facility.

LPA observed a locked centrally stored medication cart located inside the medication room, in both Assisted Living and Memory care units. Medications were organized in separate bins for each resident. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records (CSMR) were reviewed and found to be complete.

LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted monthly, with the most recent drill completed on 01/31/2025.

The following updated forms are requested to be submitted to CCLD by 03/26/2025:

• LIC 500: Personnel Report
• LIC 308: Designation of Facility Responsibility
• LIC 400: Resident Cash Resources Affidavit
• LIC 402: Surety Bond
• LIC 999: Updated Facility Sketch (Floor Plan)
• Certificate of Liability Insurance
• Administrator Certificate(s)

An exit interview was conducted with the Assistant Executive Director. A copy of this report was left with the Assistant Executive Director, Brisa Romero, whose signature on this form confirms receipt of the report.