The facility consisted of one building with two floors with a combination of assisted living on both floors and memory care (Life Guidance) on the first floor. The ED informed the LPA that the facility had 92 residents in care at the time, including 70 in Assisted Living and 22 in memory care.

At 9:12 AM, LPA initiated a walk-through of the facility, accompanied by ED.

LPA inspected randomly selected ten (10) resident rooms in Assisted Living and Memory Care units. The rooms were found to be clean, well-lit, and equipped with the required furniture. LPA inspected the private bathrooms in random rooms. The bathrooms contained soap, grab bars, towels, a trash can, and non-slip flooring. The hot water temperature at the sink faucets measured between 119.3°F and 129.6°F. “Oxygen in Use” signs were observed posted outside the residents’ room where oxygen was administered. At 9:38 AM, a pillbox containing medication was observed in the R2's room #110.

LPA inspected the main kitchen and found it clean. The refrigerator, freezer, and pantry cabinets were checked, and there was a sufficient supply of fresh perishable food for two (2) days and nonperishable staples for seven (7) days. No expired food items were found. Open food items were wrapped and dated. The dining rooms in Assisted Living and Memory Care was inspected and were found to be clean, with all furniture in good repair.

Continued on LIC809-C

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

LPA inspected activity areas, library, game areas, lounges, and other commons areas and observed residents actively engaged in recreational programs and activities. All common areas were free from obstructions, and hallways were well-lit.

LPA inspected the fire extinguishers mounted on the hallway walls in Assisted Living and Memory Care and found them fully charged, with the last service tag dated 01/03/2025. ED tested the carbon monoxide detector in the hallway in LPA’s presence, and it was found to be functional. LPA reviewed the Fire Prevention routine inspection report, conducted on 02/24/2025, by the Department of Public Safety Fire Prevention & Hazardous Materials Certified Unified Program Agency, City of Sunnyvale.

LPA toured the outside courtyard and patio areas and found passageways in good condition, free of obstructions, and without any blocking or tripping hazards. These areas had patio tables, chairs, and umbrellas for residents’ use. Delayed egress was observed on emergency exits. No accessible bodies of water or hazards were observed.

LPA observed locked centrally stored medication carts in the Assisted Living and Memory Care units. Medications were organized separately for each resident. Narcotics were locked. All medication bottles and bubble packs were properly labeled. At 11:16 AM, Centrally Stored Medication Records were reviewed, medication count check was performed. LPA observed that the medication counts for 3 medications for 1 of 5 residents was found to be inaccurate and one less medication was administered to R1 for those 3 medications.

LPA reviewed six (6) staff personnel records and five (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. At 11:48 AM, The LPA observed that 3 of 5 residents did not have Safeguards for property/valuables inventory filed, dated, and signed. R2's LIC602 Physician's report stated that R2 had MCI and didn't mention that R2 can manage medication on their own (a pill box with medication was observed in R2's room). LPA observed that 6 of 6 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 6 of 6 staff members were associated with the facility.

Continued on LIC 809-C

The following updated forms are requested to be submitted to CCLD by 06/12/2025:

• LIC 500: Personnel Report
• LIC 308: Designation of Facility Responsibility
• Certificate of Liability Insurance
• Administrator Certificate(s)

An exit interview was conducted, and Plans of Correction were reviewed and developed with the Executive Director. A copy of this report and appeal rights were discussed and provided to the Executive Director, Flavio Silva, whose signature on this form confirms receipt of these documents.