Routine inspection·July 24, 2025

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct an annual inspection of this 3 story 36 apartment (some shared) RCFE with a plan of operations for Dementia and was greeted by staff. LPA met with Administrator Lauren Cottman and Business Office Director (BOD) Ravi Banwait. The facility has a fire clearance approved for 55 Nonambulatory residents on the 2 nd and 3 rd floors with magnetic locked egress doors and gates on all patios and levels, last effective date of 8/20/2019. A Hospice Waiver approved for 12. There is a total of 26 residents of which 4 are under Hospice care. At approximately 8:45AM, LPA toured the community with staff & BOD. The tour of the facility included ten resident apartments, activity rooms, salon, dining rooms, kitchen and outdoor patios. All interior parts of the facility were found to be a comfortable temperature measuring between 75 to 78 degrees F. Exits and pathways were free from obstruction. Delayed egress doors have audible alarms when doors are opened without access codes. Facility serves residents with dementia and has special care plan of operation and programming. Hot water temperature measured between 115.3 degrees F and 121.2 degrees F not within regulation of 105 to 120 degrees F in six of ten rooms tested (see LIC809D). Bathrooms contained necessary grab bars and slip-resistant mats, strips, or flooring in all bathtub and or shower floors as required by Title 22 Regulations. There was a supply of cleaners, hygiene products and paper products available for residents. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for residents in care. Food was found to be handled and stored in a safe manner. Dining rooms and kitchenettes were inspected. Menus with snacks and beverages are available to residents. Activity schedules are posted and at approximately 9am LPA observed activities director conducting morning activity and at approximately 4pm observed live music being played for monthly birthday party. Continue on LIC809C Continue from LIC809 LPA was informed there was only 1 med tech and 2 caregivers for entire facility during morning shift of 26 residents of which 10 are two person assist and 16 one person assist which is a violation of personal right 87468.2(a)(4) see LIC809D. Facility has multiple indoor and outdoor sitting areas and a private dining area. Toxins are stored in a locked laundry and housekeeping closet; although at approximately 9:15am Housekeeping closet was found unlocked with toxic cleaning chemicals including Mold Armor Rapid clean remediation (see pics & LIC809D). Also in resident (R3’s) room LPA observed unlocked bathroom cabinet with razors and supplies (see pics). A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. A sample review of six resident & five staff records as well as three resident’s medications was conducted. LPA reviewed resident’s files at 10:45 AM on 7/24/2025 and learned that 6 out of 6 residents have an updated reappraisal/needs & care plan on file. Medical assessments of 1 out of 6 residents was absent during inspection, as required by Title 22 Regulation (see LIC809D). In addition, as per ED facility has no residents with pressure sore as of 7/24/2025. Medications were centrally stored in a locked medication cart in the facility medication room. The Medications of 3 out of 3 residents were found to be given according to physicians’ directions on 7/24/2025 at 10:20 AM. Centrally Stored Medication Record (CSMR) of 3 out of 3 residents were found to be accurate. LPA conducted a sample review of staff records at 1:15 PM on 7/24/2025 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements as per Title 22 Regulations and H&S Code. LPA was presented with proof of CPR & 1 st Aid certification for all staff. Lauren Cottman Administrator Certificate # 7028976740 expires 9/21/2026. Fire Extinguisher was found to be last charged on 9/10/2024 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 4/14/2025. LPA & Administrator were unable to locate Carbon monoxide detectors or records indicating they were attached to smoke detector system (see LIC809D). There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Continue on LIC809C2 Continued from LIC809C In addition, LPA advised to ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have been conducted monthly in different shifts with the last one on 6/6/2025. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. LPA Hansen is requesting Licensee to update and submit the following documents by 8/14/2025: LIC 308 Designated LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurance