Routine inspection·April 21, 2025

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA met with Andrew Villegas, Nurse Supervisor and explained the purpose of the visit. Shortly after, LPA met with Jeremiah Hovsepian Bearce, Executive Director and Eusebio 'Sev' Tienda, Director of Wellness who both assisted LPA with the inspection. The facility is licensed to serve (200) non-ambulatory residents age 60 and above. Hospice waiver approved for (6) residents and Memory Care approved for (12) residents. Facility is approved to lock both exterior doors on the perimeter gates in the Memory Care unit (Hacienda Bldg.). Facility is a Continuing Care Retirement Community (CCRC) which includes separate buildings throughout the premises. The Assisted Living residents are located in the Memorial Lodge (ML) and Shu Lodge (SL). Memory Care Unit which is located in the Hacienda Building, is approved for 12 residents. Currently, there are 29 residents in the Assisted Living, 10 residents in Memory Care and 107 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's Infection Control Plan was recently reviewed and updated on 03/17/2025. Staff are adhering to infection control requirements. The facility allows visitors, such as ombudsman and advocacy representatives to see residents privately at reasonable hours and without prior notice. Operational Requirements: T he Infection Control Plan has been included to the Plan of Operation. Hospice Waiver for 6 is approved and there are (6) residents receiving hospice care, (0) bedridden . A fire clearance is in place. Fire Drill was last conducted on 03/13/2025. Liability Insurance is in place and expires on 01/01/2026. Physical Plant & Environment Safety: LPA toured the physical plant areas inside and outside and was accompanied by Andrew Villegas, Nurse Supervisor. The facility is a gated community with multiple single story buildings to accommodate Memory Care, Assisted Living and Independent Living residents, all arranged in a campus-like setting. LPA toured a random selection of resident rooms in the Assisted Living (Memorial lodge and Shu lodge) and Memory Care unit (Hacienda bldg.). Resident rooms were furnished appropriately. Each resident room has their own bathroom. The bathrooms were observed to be clean, operational w/grab bars and have slip-resistant mats. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. The facility has central air and heating accommodations. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. There are various yard areas throughout the facility that are equipped with patio furniture for residents' comfort and safety. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility are operational and compliant. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. ***CONTINUED ON LIC-809-C*** Staffing : Facility employs a sufficient number of staff including night staff that are trained and able to provide care and supervision to the residents in the event of an emergency. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records-Training : LPA reviewed staff files and verified health screenings, criminal records and fingerprint clearances. Personnel files include documentation of staff training in areas like medication assistance, postural supports, Alzheimer’s and Dementia care, health clearance, vaccinations, and 1st Aid/CPR. Administrator, Andrew Smith's certificate is valid and expires on 02/11/2027. Residents Rights-Information: The required information such as Personal rights of residents, Emergency Exiting Floor Plan, Ombudsman information, Complaint poster, Rights of Resident Councils, Visiting policy, Theft and loss policy and Emergency Telephone Numbers are posted throughout the facility. The facility has resident rights council who meet regularly. The facility provides internet services to all residents and have access to the facility phone. Planned Activities: The facility provides sufficient space to accommodate both indoor and outdoor activities. The facility offers scheduled activities and an up to date calendar is posted in separate buildings. The facility employs a full-time staff (Activity coordinator) to organize, conduct and evaluate planned activities. Food Service: Sufficient food supply is stored in the kitchen and food storage room consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and cleanliness in the kitchen were observed. Some kitchen staff workers were observed to be using hairnets and disposable gloves while working. Incidental Medical & Dental: Medications are centrally stored and properly labeled in their original containers or bubble packs. Facility has (2) medical carts and uses eMar called point-click care to document residents medications. A complete first aid kit is maintained in the medication room. Memory Care and Assisted Living have their own medication room. LPA reviewed multiple residents medications in the medication room with no issues observed. Resident Records-Incident Reports: Resident files are maintained in the business office. A total of (10) resident files were reviewed. Resident files contained Admission Agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical Consent and Medication Records. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers in place. Emergency training such as earthquake drill, elopement and evacuation procedures are conducted on a quarterly basis. Evacuation procedures, including emergency exits are included in the facility sketch. Residents with Special Health Needs: Facility admits residents with dementia and staff files reviewed today all have required training documented. LPA observed 'no smoking oxygen in use' signs posted in some residents' rooms. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays' visit. Exit interview held and a copy of the report was provided to Director of Wellness Eusebio 'Sev' Tienda.