Routine inspection·October 21, 2025

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry and met with Tana McMillon, Regional Vice President of Operationsr at 12:30pm and explained the purpose of the visit. The facility is a two-story building with a capacity of seventy non-ambulatory residents; of which twenty-five may be bedridden. The facility is divided into two communities. The first level is the Birch community and the second level is the Peppertree community. The facility currently has a census of forty-three residents in care. During today's visit, LPA toured the facility and inspected the physical plant . LPA tested hot water temperatures in five of five resident bathrooms. The hot water temperature measured between 107.9 and 113.0 d egrees Fahrenheit . Resident apartments had the required furnishings and were clean with no hazards observed. The fire sprinklers, smoke alarms and carbon monoxide detectors are tested annually and were tested on October 17, 2024. The next test is scheduled for November 11-12, 2025. The Director of Plant Operations (DPO) will email LPA with results from the November 11-12, 2025 inspection. There are fourteen fire extinguishers throughout the community and they were charged and were serviced on May 21, 2025. The facility’s last fire drill was conducted on September 7, 2025 and evacuation chairs were observed in stairwells. LPA and DPO tested the delayed egress doors in the Birch neighborhood and egress door released after thirty seconds. (Continued on LIC 809-C) (Continued from LIC 809) LPA inspected the kitchen food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand . The walk-in refrigerator had a variety of fruits and vegetables and a temperature log is updated daily. The kitchen is secured with a keypad so only staff are able to enter. Knives are secured in the kitchen. Emergency supplies were in the storage room and water is stored outside. Hazardous chemicals are stored in a locked storage room. The Birch Community has a meditation room/theater and residents were observed listening to soothing music in the common area. There is a courtyard where residents and family members were visiting and there were shaded seating areas. The were no hazards obstructing hallways or walkways. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. First Aid Kits were observed in the medication rooms with the required elements. LPA pressed a resident pendant and staff came within five minutes to assist. LPA reviewed five of five staff training and fingerprint record s and reviewed five of five resident records . LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that the administrator has a current administrator certificate which expires on November 18, 2026. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Tana McMillon, Regional Vice President of Operations and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.