Routine inspection·May 9, 2025

Licensing Program Analyst (LPA)s Mary Flores and Blanca Gonzalez conducted an unannounced annual visit at the facility using the CARE inspection tool. LPAs met with Shaun Rushforth administrator and explained the reason for the visit. Facility is licensed to serve as a Continuing Care Residential Community (RCFE-CCRC) for 340 non- ambulatory adults 60 and over, of which 5 may be bedridden in rooms 150-169. Delay Egress is approved in 1st and 2nd floors and a secured perimeter is approved in the 1st floor. Facility has an approved hospice waiver for 20 residents. Facility consist of a lobby, library, cafe, a dining room, commercial kitchen, wellness office, a swimming pool, a gym, a fitness room, craft room, lounge room, game room, activity room, other common areas in the 1st, 3rd, and 5th floor. It consist of 5 floors and a basement, 2nd - 5th floor houses residents in independent and assisted living, the first floor consist of common areas, some assisted living, and dementia unit with delay egress system. basement consist of activity areas. LPAs toured the facility with Alex Alvarado and Aura Molina the following domains were reviewed during this visit: Operational Requirements: Facility maintains a plan of operation, infection control plan, fire clearance. Facility is operating within the limitations of their license. They have 6 residents under hospice and 1 bedridden resident. A current liability insurance was observed. Physical Plant/Environmental Safety: During facility's tour LPAs observed all common areas in good repair. A total of 24 random residents' rooms for independent, assisted, and dementia unit. Each room was furnished, with sufficient lighting, and bedding supplies. Water temperature was tested in each resident's bathroom and tested between 107.7 - 122.1 degrees F., which is not within the required 105-120 degrees F. Bathrooms were observed with grab bars. (CONTINUED ON LIC 809C) The following rooms were missing skid mats/strips in the showers #553,536,542,424,403,408,240, 210, 160,167. Facility's pool has a fence surrounding. Medication is stored in medication rooms. Passageways, hallways, stairways are clear of debris and obstructions. Auditory signal/pendant buttons were tested for 3 residents and staff responded within 5 minutes. Facility has a fire sprinkler system throughout. Fire extinguishers were observed and last checked on 12/6/24. Delay egress exit doors were tested and in working condition. Elevators were observed working. Resident Rights/Information: License, Let us Know (PUB 475), Ombudsman, personal rights posters were posted in the mailing room area. Food Services: LPAs toured the commercial kitchen and observed good quality/commercial food supplies for at least 2 days of perishables and 7 days of non-perishables. Kitchen was observed clean and free of pest. Cleaning supplies were observed stored away from food supplies. Staff were observed practicing hygiene and infection prevention. A list for residents with modified diets was observed. Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in medication carts in each medication room. LPAs reviewed medication for 10 residents. A log for PRN/Narcotics medication was observed. Resident Records/Incident Reports: LPAs reviewed 10 residents files, each contained admission agreement, medical assessment, TB clearance, a current needs and care appraisal, pre-appraisal. Six residents were interviewed. Disaster Preparedness: LPAs reviewed emergency disaster plan LIC 610E(3/19) last reviewed on 6/13/24. Evacuation chairs were observed in each staircase. Emergency drills are conducted quarterly, last emergency drill was conducted on 3/25/25. Deficiencies were noted per Title 22 Regulations. LPA will return at a later time to continue annual visit and finish remaining domains. Exit interview was conducted with Shaun Rushforth and a copy of this report was provided.