Routine inspection·August 12, 2025

On 08/12/25 at 8:10AM, Licensing Program Analyst (LPA) Gina Saucedo arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with Frances Norberte, Memory Care Director and disclosed the purpose of the visit. LPA asked for the census, resident, and staff rosters and files. A physical tour was conducted at 10:05AM and observed the following: The entire facility has a total of 110 (one-hundred and ten) beds. Forty-three (43) are currently in the memory care unit and 44 (forty-four) in the Assisted Living area being occupied. All the rooms are on the second floor. The floor is divided by assisted living and memory care. The assisted living is on your left-hand side of the facility and the memory care is on your right-hand side of the facility. The second floor consists of a medication room which is in the memory care section. The memory care section has their own activity, dining hall, two (2) enclosed patio and enclosed gardens. There is also four (4) delayed egress on the doors in memory care. The assisted living side has their own activity room upstairs and another room downstairs. The assisted living side has access to the ground level which is the first floor which has the laundry room area, beauty salon, dining hall, kitchen access to the patio area, another activity room area and a staff lounge. The parking structure can be entered from this area and from the street area. LIC 809C-continued Random Bedrooms and Bathrooms were randomly selected to tour and were observed to have appropriate furniture, lightening, bedding, and televisions. Random Bathrooms were observed to have grab bars and non-skid mats. Hot water temperature was tested randomly for and measured 113-114-degree Fahrenheit. The random bedrooms and bathrooms had pull-cord alarms. The public bathrooms in the assisted living area had emergency pull-cord alarms. Fire extinguishers were observed throughout the facility and were fully charged on green with the same expiration dates- August 2025. There are fire extinguishers upstairs, downstairs, in the kitchen area and parking lot structure. Carbon Monoxide and fire sprinklers are located throughout the facility and are operable. Facility has a designated medication room that is inaccessible to residents where all the medication is stored and locked in the memory care side of the facility. The medication was revised randomly. The assisted living area: outside/backyard is accessible to residents with different areas for them to sit. There is appropriate outdoor furniture for the residents to sit on with proper shading. There is no bodies of water. Common Areas : These include the dining areas, beauty salon, and activities room. All common areas were observed to be cleaned and properly furnished. The activity room has a large television and has enough seating for several residents to watch the television and do different activities. Facility maintains a comfortable temperature of in between 74 and 77-degree Fahrenheit. There are several temperature thermostats throughout the facility. There are several common bathrooms throughout the upstairs and downstairs area. The staff and resident bathrooms are not shared. There are trash cans with lids and covid signs posted in the common bathrooms. There is toilet paper and napkins. The exit stairways leading to the downstairs area all have evacuation chairs. There are several hand sanitizers against the wall throughout the facility. LIC 809C-continued The Kitchen area was toured and observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The chemicals are inaccessible to the residents which can be accessed via the kitchen area in a locked door. Against the wall of the kitchen towards the back is a Resident's Diet Plan Board. Administrative: The Insurance plan is current and dated 10/2025. There is a disaster plan, licensee certificate, YES sign, Resident Rights, and Rights of Resident Council against the w all facing the entrance of the facility on your right hand side. The Ombudsman sign is on your left hand side of the entrance of the facility. The last fire drill/emergency drill was conducted in July of 2025. An exit interview was conducted, citation(s) were issued, appeals rights, and a copy of this report was given to the memory care director. Citations were issued on Plan of Correction of Elopement of resident on 03/17/25 which was due on 03/31/25 and was never sent to Community Care Licensing/LPA and the garage area has hazardous materials such as bed mattresses and sofas next to parking spaces that need to be disposed of or stored in a storage area.