Routine inspection·March 17, 2025

Licensing Program Analysts (LPAs) Quoc Huynh and Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:57 AM. LPAs met with facility Administrator Grace Hartnett. Entrance interview conducted and the reason for the visit was explained. The facility has several floors divided into separate areas of memory care, assisted living, and independent living occupants. The facility is licensed in Building A on the 1st, 2nd and 3rd floor and In Building B, only on the 2nd floor. There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature at approximately 72 degrees. Beginning at 10:46 AM, the LPAs, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS : There are One-Hundred sixty-three (163) bedrooms in the facility. LPAs and facility Administrator toured seventeen (17) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPAs observed one (1) resident room to contain a ripped balcony screen door. LPAs tested the emergency pull cords in two (2) resident rooms. The staff's response time did not exceed 10 minutes. BATHROOMS : All resident bedrooms in the facility have attached private bathrooms and shared bathrooms are located throughout the common areas of the facility. All bathrooms LPAs inspected were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all showers and near all toilets, all were properly secured. The water temperature was measured between 107.8 and 114.6 degrees Fahrenheit, which is in compliance with regulation. Continued on LIC 809C. COMMON AREAS : LPAs observed cameras to be located throughout the facility’s hallways. LPAs observed the facility’s activities room, libraries, theater, salon, art gallery, and gym. All common area rooms were observed to be clean and in good repair. All furniture observed was in adequate condition and was free from rips and tears. LPAs observed locked janitorial closets and laundry rooms throughout the facility’s hallways. The facility has adequate indoor space to accommodate resident’s activities. LPAs observed the entryway of the facility to contain an fireplace. It is appropriately screened and contains no tools. LPAs observed a fire extinguishers located throughout the facility to be last serviced on 08/28/2024. LPAs tested the facility’s fire alarm system at 01:50 PM. All alarms and fire doors observed functioned properly at the time of the test. OUTDOOR SPACE: LPAs observed the outdoor spaces of the facility. LPAs observed two (2) terraces and one (1) outdoor yard. LPAs observed the outdoor yard to contain an appropriately fenced off pool, a greenhouse, and planter boxes utilized for resident activities. LPAs observed one (1) of the terraces to have two (2) window screen frames that were observed to be in disrepair. KITCHEN/DINING ROOM : The LPAs observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPAs observed the kitchen to contain adequate emergency food supplies. LPAs observed the kitchen entrance to be under staff observation. LPAs observed the dining room to be clean and properly furnished at the time of the visit. The dining room contains adequate seating and tables for resident use. MEDICATION REVIEW: Medication review began at 02:00 PM. Medications are stored centrally and securely in two (2) medication rooms located in each wing of the facility. LPAs observed medications for seven (7) residents. One (1) resident’s medications were observed to be documented incorrectly on their centrally stored medication and destruction record sheets. INTERVIEWS: LPAs interviewed five (5) residents. All residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility. Continued on LIC 809C. During today’s visit LPAs obtained a copy of the facility’s resident roster. Due to time constraints LPAs will return at a later date to conduct employee interviews, conduct resident and staff file review, review the facility’s emergency disaster plan and infection control plan, and to obtain copies of the facility’s LIC 500 and liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.