Routine inspection·August 7, 2024

Licensing Program Analyst (LPA) Antonia Alvizar- Ettima and Licensing Program Manager (LPM) Naira Margaryan conducted unannounced Required 1-year inspection to the facility. LPA and LPM met with the Resident Health Services, Ruzana Sergeyen and Director of Resident Services Kohar Kelkelyan. At 10:08AM the Executive Director, David Weidert joined us. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools. At about 10:35AM, with the assistance of the Environment Services (EVS) Celina Miranda and Executive Director, David Weidert LPA Alvizar – Ettima and LPM Margaryan conducted a tour of the facility inside and out. The facility consists of 4 main buildings. The Independent Living section of the CCRC includes floors 1 through 4 of the "Main" building and 3 separate multi story Villa's named Marsten, Green and Hunt. The independent living units have their own laundry, kitchen, bathrooms, living rooms and dining area. There is a separate beauty salon and a spa “Mariposa” on first floor. There is a swimming pool and of which is completely fenced with 5-foot-high fencing. The gates are locked. The independent residents are given Fob key for access. There are two restaurants, Theater, Fitness Room, Art Studio, Library, Card Room, Bar “Station 8”, Grab & Go snacks, Auditorium/Chapel, Multiple Activity spaces and available to the independent residents. There is a fountain located at the independent living entrance that is grated with large stones that will only allow 3 inches of water on the surface. The Memory Care Unit had 20 studio rooms with bathrooms, a dining area, a courtyard, food servicing area, laundry area, and medication room. The memory care unit had delayed egress and roam alert. At 12:00PM LPA and LPM checked the egress alert and functioned properly at the time of this visit. Roam alert is located leading into the Terres area and all the exits. During todays inspection LPA Alvizar-Ettima and LPM Margaryan inspected independent living apartments and spoke with the residents present in their apartment. The hot water in the bathrooms of the independent living apartments as well as in the community bathrooms, was tested between 115.5*F and 118.0*F. At 12:28PM, LPA Alvizar – Ettima and LPM Margaryan reviewed six randomly selected residents record, residing at the Independent Living and Dementia apartments. During inspection, LPM and LPA observed memory care residents having lunch. One of the staff was feeding a resident by putting the spoon in resident’s mouth. LPM Margaryan spoke with the Resident’s Care Director and other staff available in the dining area and discuss the personnel requirements and training for the staff feeding residents vs providing assistance with food intake. Residents Care Director and ED were advised that to promote resident’s independency, the staff should only provide feeding assistance by using training tools and other technics to prolong residents independency as long as possible. Upon review of the Care and Residence Agreement, LPA Alvizar-Ettima and LPM Margaryan noted that the agreements does not contain additional addendums to the original agreement/contract regarding the annual fee increase and/or service fee increase based on noted changes in residents physical and mental conditions. Other minor issues regarding residents’ appraisal, need and service plan as well as the usage of the facility amenities, including the pool. The administrative personnel were advised that the facility should have a plan in place explaining how they are assisting residents, that are using a pool, to ensure that their health and safety is being protected. Prior to entering the facility LPA Alvizar - Ettima and LPM Margaryan noted the construction work next to the facility. There were signs posted through the construction site advertising “MonteCedro expansion coming soon.” ED stated that they are working on a new project trying to expend Montecedro. ED was able to explain what they have done up to date and how they inform the residents and try to accommodate them during construction. LPM advised ED to provide written statement explaining the steps they are following to ensure that residents are accommodated during construction period. No citations were issued during this visit. However, ED was advised that that all noted issues (discussed during this visit) that may pose potential risk to the health and safety of residents in care, should be addressed in writing and the documentation must be submitted to CCL no later than by COB 08/12/2024. Exit interview was conducted and a copy of report was issued.