Routine inspection·March 24, 2026

Licensing Program Analysts (LPA) Zabel Chochian arrived unannounced to conduct a required annual visit. Upon arrival, LPA met with Executive Director (ED), James Mackay, and Assisted Living Director, Shaulett Dela Cruz. The reason for the visit was stated. Entrance interview conducted. Copy of the residents and staff roster obtained. Current census is 52 of which three (3) residents are receiving hospice services and ten (10) residents are receiving home health services. Facility's approved Infection Control Plan and Emergency Disaster Plan was reviewed with the ED. Both plans have been reviewed with in the year and no changes were made. The facility has a comprehensive disaster plan. Emergency disaster drills are conducted quarterly as per regulation; monthly fire drills conducted the last one being a fire drill and was conducted in 02/2026 and major disaster drills conducted quarterly; last one being an earthquake drill (great shake out) in 10/2025. At approximately 12:30 p.m., LPA, ED, Assistant Director Shaulett Dela Cruz and Safety Director John Miller and his team toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. COMMON AREAS: The facility is a two story building; units are designated for assisted living residents on the first and second floor, and a separate unit on the first floor is designated for dementia care. There were no obstructions and/or tripping hazards observed. The facility maintains a comfortable temperature. The fire extinguishers were charged and last serviced 1/23/2026. Smoke Detectors and Carbon Monoxide detectors were tested by Service Pro-Fire Protection Inc. on 12/8/2025; all were found functioning properly. Individual smoke and carbon monoxide detectors in resident rooms were tested during today's visit by the Safety team. Seven out seven room smoke and carbon monoxide detectors tested were operational.(Continue to Lic809c) There are four (4) stairwells that all have emergency evacuation chairs. ACTIVITIES: Planned activities are offered, and the activity schedule was posted. Activity rooms and common spaces appeared clean and in good repair. KITCHEN: At the time of the visit, there was a sufficient supply of perishable and nonperishable food. Refrigerator, freezer, and pantry/storage area were observed; food labels were observed and checked for expiration dates, and food labels had dates clearly marked. The facility also has an emergency supply of food and water good for current census (residents and staff). The weekly menu was posted by the dining room entrance. Appliances appeared to be clean and in operable condition. Dining room also observed clean and appropriate furnished with tables and chairs. BEDROOMS: LPA toured ten (10) randomly chosen rooms; two (2) in memory care, and eight (8) in assisted living. Rooms appeared clean, well kept, with sufficient lighting and appropriately furnished. Eight (8) out of ten 10) residents were interviewed during the tour. RESTROOMS: Restrooms on all floors were clean and sanitary. Restrooms were fully stocked with supplies. The hot water temperature was tested on all floors and ranged from 107.5- and 118.7-degrees Fahrenheit. OUTSIDE AREAS: LPA observed appropriate outdoor furniture with a covered shaded area for residents. There was an enclosed patio for residents who reside in the memory care unit. MEDICATIONS: Medications are centrally stored in the medication room; there is a medication room on each of the two (2) floors and one (1) in the Memory Care Unit. Random resident medication review conducted on each floor medication room including the memory care unit; PRNs observed with physicians order on file; residents medications observed recorded on the centrally stored log; Medications appeared to be given as prescribed. Some records were missing start dates; staff recorded the start dates from the bubble pack. In-service training provided during today's visit. No citations issued during today's visit. LPA will return to review personnel and resident records on a later date. Exit interview conducted. Copy of report was provided.