LPA initiated a walk-through of the facility, accompanied by ED.

LPA inspected randomly selected ten (10) resident rooms (#425, 402, 337, 318, 232, 227, 220, 208, 122, 108) in Assisted Living and Memory Care units. The rooms were found to be clean, well-lit, and equipped with the required furniture. Emergency pull cords were observed to be functioning in the resident rooms with an average response time of 2 minutes. 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 114.4°F and 119.5°F.

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 07/11/2024. All common areas were free from obstructions, and hallways were well-lit. The smoke detectors are tested semi-annually by a third-party vendor, JCI. A staff member tested the carbon monoxide detector in the resident room in LPA’s presence, and it was found to be functional.

LPA observed bistro areas and recreational rooms such as activity rooms, PT/OT room, gaming area, library area, and town hall for events, movies, and other activities. The residents were seen actively engaged in recreational programs and activities.

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 toured the garden and patio area and found ramps and 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 and patio doors were locked. No accessible bodies of water or hazards were observed.

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. 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.

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. Centrally Stored Medication Records 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 (Fire and Earthquake) Drills were conducted monthly, with the most recent fire drill completed on 02/27/2025.

The following updated forms are requested to be submitted to CCLD by 04/24/2025:

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

An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Tyler Manzo, whose signature on this form confirms receipt of the report.