Routine inspection·August 18, 2025

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 10:25AM for a required one-year visit. The LPA met with the Executive Director (ED) Kathleen Glass and explained the reason for the visit. Entrance interview conducted. At 11:02AM, the LPA and ED 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. The following was observed: RESIDENT ROOMS: The LPA observed ten (10) randomly selected rooms on the first and second floors and no immediate health or safety hazards were observed. Appropriate furniture was observed in each unit. Restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Water temperature was tested throughout the units and measured between 113.5 degrees F and 117 degrees F, which is within the required range. At 11:31AM, the LPA tested the facility’s pull cord with staff response at 11:33AM. Report Continued on LIC 809-C KITCHEN: The facility’s dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. Facility uses third party vendors and receives food deliveries about twice a week. There was a sufficient supply of perishable and non-perishable food. The LPA observed the walk-in refrigerator and freezer; food appeared to be of good quality and labeled with expiration dates. Kitchen sinks had signage of tap water delivering above 125 degrees F. Emergency food and water was observed to allow the facility to be self-sufficient during an emergency. COMMON AREAS: The facility had two (2) total floors with resident units, medication rooms, offices, resident lounges and treatment rooms. Additional buildings contained resident recreation center, synagogue, dining area, kitchen, grab-n-go café, administrative offices, and medical clinic. The facility also shares outdoor space with Fountainview at Eisenberg Village and a Nursing School. LPA Huynh observed common areas to be clean, clear of obstructions/hazards, and furniture was in good condition with patios/courtyards providing shade for residents. Required postings were temporarily stored in an office as the facility had recently repainted the walls. There were no bodies of water observed during today’s visit. There were fire extinguishers throughout the facility, which were serviced on 01/30/2025. RECORDS: Record review began at 12:03PM. LPA Huynh reviewed five (5) files for, but not limited to: admissions agreements, medical assessment, appraisals, and consent forms. Resident records reviewed were in order at this time. The LPA reviewed five (5) personnel records for, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification, and appropriate training. Staff files reviewed were in compliance with regulation at this time. Report Continued on LIC 809-C INFECTION CONTROL/EMERGENCY DISASTER: The LPA reviewed the facility's Infection Control Plan and Emergency Disaster Plan. LPA noted that the facility is in compliance with regulation with both plans reviewed annually. The facility conducts emergency disaster drills as required, with the last drill documented on 06/29/2025. Fire alarm system is tested annually with the last inspection between 06/23/2025 to 06/27/2025 with a follow up inspection to be determined. MEDICATION: Medication review began at 3:02PM. The LPA reviewed medications for four (4) residents. Medications were maintained inaccessible to residents in the medication room located on the first and second floor. Resident medications reviewed were documented and stored in compliance with regulation at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.