Routine inspection·October 14, 2025

Licensing Program Analyst (LPA) Daniel Konishi conducted the required unannounced annual inspection. LPA met with Director of Wellness, Eusebio Tienda and explained the purpose for the visit. The facility is licensed to serve a capacity of two hundred (250) residents ages 60 and above, with a maximum of (25) Non-Ambulatory in the Bradbury Building. There is an approved Hospice Waiver on file for four (4) residents. The facility also has an approved Dementia Care plan as part of their operation. There are currently 24 residents in Assisted Living and 184 residents in Independent Living. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an Infection Control Plan in place which was last updated on 08/05/2025. Emergency and disaster plan was completed and up to date. Operational Requirements: The facility has an approved fire clearance and facility maintains the required liability insurance in place. There is an approved Dementia Care plan in place. Last fire drill was last conducted on 09/22/2025. Physical Plant & Environment Safety: This is a Continuing Care Retirement Community (CCRC) which includes separate buildings throughout the premises; Independent Living, Assisted Living and Skilled Nursing. The Assisted Living residents reside on the second floor of the Bradbury Oaks building and other residents are at the Independent Living care section. The wander guard system is used in the Bradbury Oaks building (second floor) for residents diagnosed with dementia or wandering behaviors, this was tested during visit and was in order. Physical Plant & Environment Safety [Cont.]: LPA inspected six (6) residents' rooms and each resident bedroom has the required furniture such as the bed, bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, skid matt/strips and shower chair. The hot water temperature was tested throughout the facilities resident’s six (6) private bathrooms and measured between 114.9 degrees F to 116.6 degrees F which are within the required range of 105-120 degrees. Cleaning supplies are secure, locked and inaccessible to residents. Sharps are secure, locked and inaccessible to residents. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged and last inspected on 04/14/2025. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. There are multiple shaded patio/garden areas for residents. Staffing : There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training : LPA reviewed five (5) staff files that included personnel record, criminal record clearance, health screening, TB clearance, Employee Rights, valid First-Aid/CPR/AED training, and staff training. Executive Director/Administrator, Andrew Smith certificate expires on 2/11/2027. Residents Rights-Information: Residents are provided with telephone and internet access at the facility. The facility has the following posters posted throughout common areas: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There is sufficient space both indoor and outdoor for activities. Food Service: Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables, along with the emergency food supply. Incidental Medical & Dental: Medications were reviewed for five (5) residents to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are centrally stored and in their original containers. Medications are administered as prescribed by the Physician. Medications are bubbled packed and in bottles. The first Aid kit was observed and has all required items. Resident Records-Incident Reports: LPA reviewed five (5) resident files which included Face Sheet, Pre-admission Appraisal/Assessment, Service Plan, Admission Agreements, Physician's Report, Ambulatory Status, TB Clearance, and Personal Rights. There were no issues observed. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least two (2) relocation sites. LPA observed the Evacuation chairs mounted near the stairway. The last drill was conducted on 9/22/25 in the assisted living (Bradbury Building). Residents with Special Health Needs: Per Director of Wellness, there are one (1) residents under hospice care, (0) residents receiving home health services and two (2) residents using oxygen have "No smoking in use" signs posted. Dr.’s Order for one (1) resident’s Hospital Bed is in file. Facility has hospice care plan in place. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during today’s visit. Exit interview was held and a copy of the report was provided to Director of Wellness, Eusebio Tienda.