Routine inspection·January 21, 2026

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 9:36AM for a required one-year visit. The LPA met with the Executive Director (ED) Kathleen Glass and Director of Health Services (DHS) Clarissa Townes and explained the reason for the visit. Entrance interview conducted. At 10:15AM, the LPA, ED, Business Administrator, and Director of Maintenance 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 four (4) floors and no immediate health or safety hazards were observed. Appropriate furniture was also 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 115.3 degrees F and 120 degrees F, which is within the required range. At 11:03AM, the LPA tested the facility’s call system pendant with staff response at 11:05AM. Report Continued on LIC 809-C COMMON AREAS: The facility had five (5) total floors. The basement contained the parking garage, theater, and emergency food and water. The first floor contained resident apartments, fitness center, spa, lobby/concierge, library, coffee bar, business offices, events center, creative arts room, private dining room, lounge, dining room, and kitchen. The second, third, and fourth floors each had resident apartments and lounges. LPA Huynh observed common areas to be clean, clear of obstructions/hazards, and furniture were in good condition. Required postings were observed in the lobby. KITCHEN: The facility’s commercial kitchen was inspected and found to be in compliance with Title 22 regulations. Facility uses third party vendors and receives general food deliveries three (3) times a week and protein deliveries daily. 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. MEDICATION: Medication review began at 11:36AM. The LPA reviewed medications for six (6) residents. Medications were maintained inaccessible to residents in the medication room located on the fourth floor. Resident medications reviewed were documented and stored in compliance with regulation at this time. OUTDOOR AREA: The facility’s outdoor area consisted of four (4) courtyards with one (1) water fountain. The facility also shares outdoor space with Eisenberg Village and a Nursing School. Residents have the option of utilizing the common spaces offered at the connected facility. The exterior perimeter was secured with gates and held multiple emergency exits. All passageways were clear of obstructions. Report Continued on LIC 809-C RECORDS: Record review began at 12:41PM. LPA Huynh reviewed ten (10) resident records for, but not limited to admissions agreements, medical assessment, appraisals, and consent forms. Seven (7) residents did not have consent forms, and four (4) residents did not have signed personal rights. The ED and DHS stated they plan to provide all residents with new forms to complete. The LPA reviewed ten (10) 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. Two (2) direct care staff annual training reviewed did not include dementia, hospice, postural support, and restricted health condition topics. The LPA and ED reviewed training regulations including topics and hours. The LPA advised the ED to ensure training hours are also disclosed on all training documents. INFECTION CONTROL/EMERGENCY DISASTER: T he 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 11/29/2025. There were fire extinguishers throughout the facility, which were serviced on 01/30/2025. Fire alarm system is tested annually with the last inspection on 11/24/2025 by AB&A Fire Protection. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.