Routine inspection (multi-day)·May 1, 2025

On May 1, 2025, Licensing Program Analyst (LPA), Deborah Lee conducted an unannounced Case Management Continuation visit using the CARE Inspection Tool to continue the annual required visit started on April 23, 2025. LPA Lee met with the Co-Administrator Peggy Clark and the purpose of today’s visit was explained. The facility is licensed to operate for 262 non-ambulatory residents, of which 10 may be bedridden, ages 60 and over. The facility has an approved Hospice Waiver for 10. The census for today is 142. Facility's Annual fees are current. Physical Plant/Structure The facility is a large, two-story, building located in a commercial neighborhood. The facility has a memory care unit and an assisted living unit; the assisted living unit consist of two floors which includes resident rooms, common areas, dining area, kitchen, an outdoor shaded area, a laundry room, reception area and administrative offices. Memory care unit consist of two floors, resident rooms, dining area, common area, a theater, and delayed egress doors. The facility has a signal system with a switch board located in the reception area and is operational from all residential living units. Page 1 of 2 File Review: LPA reviewed (7) resident files and found that ( 7 ) out of ( 7 ) had the required documents. LPA reviewed (7) staff file and the Administrator file and found that (6 ) out ( 7 ) had the required documents, training, and certifications. LPA found that The facility Administrator's certification expired. Administrator is in process of completing the required course work to recertify. Medications: LPA observed all centrally stored medications secured in a locked med cart in the locked medication room and are inaccessible to residents. All medications were observed in their original packaging. LPA reviewed the medication for (7) residents. LPA observed ( 7 ) out of ( 7 ) resident’s medication were properly maintained and are consistent with properly documented records. LPA's observed a monthly schedule which presented a sufficient number of daily activities for facility residents. LPA observed the noted activities being conducted in the activities area, which is directly across from the TV lounge area. During today’s visit LPA cited Title 22 Division 6 chapter 8 Article 7 for 1 deficiency. See 809D. An exit interview was conducted with Administrator Veronica Gomez, and a copy of this report was provided. Page 2 of 2