Routine inspection·April 24, 2025

License Program Analyst (LPA) Shannan Hansen arrived at facility to conduct an unannounced annual inspection and was greeted by Bill Phelps, Interim Administrator. Facility is 2 stories with 84 AL apartments & 2 memory care units totaling 34 apartments. Fire clearance has been approved for 150 non-ambulatory residents, of which 35 may be bedridden, by the County Fire Department. There is currently a total of 121 residents, of which 33 are living in memory care, and 13 residents under Hospice care. Facility tour/inspection began at 9:00 AM: LPA toured the community with Interim Administrator. The tour of the facility included 15 resident apartments, activity rooms, Library, 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 obstructions. The assisted living residents also have an outdoor patio courtyard. Delayed egress doors from the memory care units (Lee’s Lane & Hogan’s Court) have audible alarms when doors are opened without access codes. Hot water temperature in 15 total rooms of AL & MC measured between 112.8 degrees F to 132 degrees F. with 14 rooms not within regulation of 105 to 120 degrees F. Temperature immediately turned down and per Administrator, plumber was contacted to assess issue following day (see LIC 809D) Resident bathrooms had required slip resistant mats and grab bars. While touring facility at approximately 9:36 AM to 11:00 AM LPA and Interim Administrator observed 4 storage closets ( in MC & AL) unlocked containing multiple gallons of paint, toxic chemicals, cement, cleaning products (see pic & LIC 809-D), staff locked doors. 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 kitchen were inspected and maintained per regulation. Menus with snack and beverages are available to residents. Activity schedules are posted. Facility has a theater and multiple indoor and outdoor sitting areas and a private dining area. Continued on LIC809C Continued from LIC809: Fire extinguishers were last serviced 1/8/2025. Fire safety system including smoke detectors and carbon monoxide detectors and sprinklers were last tested by Central Marin Fire Dept. on 11/13/2023 having a 5 year check next due 2026. Fire department conducted Kitchen inspection 2/2/2025 which fully passed along with the elevator. Disaster drills are conducted quarterly with the last being 3/7/2025. Facility has a permanently installed generator to power entire facility should there be a power outage. At approximately 12:30 AM, LPA reviewed 10 resident records and found 10 of 10 residents have current physician's reports and updated care plans. 10 of 10 records contained current and signed admission agreements and medication records are thorough and contained physician's orders for each resident. LPA reviewed centrally stored medication record and found to be in compliance. At approximately 1:45 PM, LPA reviewed 10 staff records. All records contained documentation of completed training as required. Evidence of current first aid and CPR training were present for required staff. All staff had required criminal record clearance and were associated. Rabah Sbaitan Administrator Certificate 6071494740 expires 7/24/2026. LPA observed Interim Administrator William Phelps Administrator Certificate pending. All fees are current. CCL had not received any incident reports since 3/3/2025 & inquired. LPA was presented with 6 Incident Reports, one a Death Report that occurred from 3/9/2025 to 4/18/2025 that are to be submitted within seven (7) days. Interim Administrator advised staff to send by fax manually as there must be a problem with the machine (see LIC809-D). 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 5/9/2025 to SRRO: LIC 308 Designation of Facility Responsibility LIC 610 Emergency Disaster Plan (if changes) Copy of current Lease Copy of Administrator Certificate Proof of Liability Insurance