Routine inspection·July 15, 2025

Licensing Program Analysts (LPAs), Martha Arroyo and Brian Balisi conducted an unannounced annual inspection today. At approx 10:15 a.m. LPAs met with Executive Director (ED)  Elizabeth Spencer and explained the reason for the visit. At approx 11:00am, the LPAs along with the Executive Director and Maintenance Director, 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: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. The LPAs observed sufficient perishable and non-perishable foods to meet the minimum two day and seven day supply of food and water. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. LPAs observed twelve (12) resident rooms randomly chosen in the main building and the six (6) surrounding buildings.  All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. The bathrooms were sufficiently stocked with supplies and paper towels. Hot water temperature was measured  between 103 – 117.1 degrees Fahrenheit. The main facility structure is a three-story building. There are resident rooms on all three floors, units are designated for assisted living residents on all three floors. In addition, there are additional resident units in six (6) stand-alone buildings.Common spaces on the first floor include the theater, salon, secured pool, and spa. The second floor includes the reception area/lobby, library, activity rooms, fitness room, and physical therapy room. The third floor includes the kitchen/dining services, and activity rooms. The pool was observed to locked and inaccessible to residents in care.  There were no obstructions and/or tripping hazards throughout the facility. The common areas were appropriately furnished, and the lighting was adequate. Smoke alarms, carbon monoxide detectors, sprinklers and fire extinguishers were observed throughout the facility. The emergency exiting plans/sketch are posted throughout the hallways. The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights. There is a functioning telephone on the premises. Emergency evacuation chairs were present in all stairways in each building. There is also a large outdoor space with shaded areas and adequate furniture for resident use throughout the facility. All passageways, walkways, driveways, steps and patios are free from obstructions and hazards at this time. Several fire extinguisher were observed throughout the facility to be fully charged and last serviced on 08/02/2024 LPAs reviewed ten (10) resident records and ten (10) personnel records starting at 12:30pm. Ten resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. (10) personnel files including the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments with TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files appeared to be in order during the visit. LPAs reviewed medications at approximately 1:30pm. The medications are centrally stored in a med rooms on the 3rd floor. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are properly documented on the centrally stored medications and destruction record.  Medications appeared to be given as prescribed at the time of the visit. During today’s visit, the LPAs reviewed the facility's infection control policy as well as their emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. The last fire safety inspection was completed on 11/7/2024 and was found to be in compliance with Fire Code Regulations at the time of inspections. Emergency disaster drills conducted as per regulation; last disaster drill conducted on 06/25/2025. No citations issued. Exit interview conducted. Report was reviewed and copy provided.