Routine inspection·May 22, 2025

On 5/22/2025, Licensing Program Analysts Arvin Villanueva and Sommer Hayes (LPAs) arrived at this facility unannounced to conduct their required annual inspection visit. LPAs met with Executive Director/Administrator Eric Hostetter (AD) and stated the purpose of the visit. This facility is currently approved to retain/accept 10 hospice residents and fire cleared to retain/accept 10 bedridden residents in the first floor only. The LPAs and ADM toured the facility to verify compliance with Title 22 regulations. The facility is a three-story building, with memory care located on the first floor. It has a capacity of 200 residents, serving independent living, assisted living and memory care. The LPAs inspected all three floors, activity rooms, dining rooms, theater room, salon, laundry room, elevator, stairwells and resident apartments/units. Second floor is where medication room is located, and medications were found to be securely stored, locked, and inaccessible to residents. 1 of 2 elevators was tested and found to be in good repair at this time. 1 of 4 stairwells were inspected and found to have evacuation chair. Per administrator, each stairwell is equipped with evacuation chair located in the third floor. LPAs observed 10 resident apartments/units (5 in Assisted Living and 5 in Memory Care) and were spacious enough to accommodate personal furnishings, and all observed units were clean, sanitary, and in good repair. Each resident unit had a smoke and carbon monoxide detector. In the Independent/Assisted Living area, each unit is equipped with their own washer and dryer. Each memory care units is equipped with electronic monitoring systems installed on the ceiling to detect falls and notify staff. Memory care also has delayed egress doors. One of the delayed egress doors was tested and found to be operable at this time. {1 of 2} The LPAs observed the kitchen area to be clean, sanitary and free of pests. The refrigerator, freezer, and pantry areas were observed to have an adequate food supply. Refrigerator and freezer were maintained within the regulatory temperature. The facility maintains a minimum of two days’ worth of perishable food and seven days’ worth of non-perishable food. All appliances were observed to be in working condition. The LPA reviewed the menu and activity calendar, and the Administrator confirmed that each resident is provided with a copy of both. During the visit, kitchen staff were preparing lunch. The LPAs observed a shaded area in the courtyard with tables and chairs, and the outdoor activity area is secure for residents. The outdoor passageways, walkways, driveways, and steps were free from obstructions and hazards. The facility does have a water fountain but it is not in use at this time. The facility has a generator to utilize during power outage. Water temperature in 2 resident units were measure between 114 and 115 degrees Fahrenheit. Room temperature in the hallways were measured between 72 and 73 degrees Fahrenheit. Review of 10 resident files (R1 - R9) which include review of Admission Agreement, Medical Assessment, Needs and Services Plan, and Ambulatory Status. No issues were noted at this time. LPAs did not conduct medication review during this visit. Facility does not manage resident cash resources at this time. Review of 10 staff files (S1 - S9) which include review of background clearance, First Aid and/or CPR, Health Screen, Initial and Ongoing Training. Per interview and record review, med tech staff are required to have current CPR certificate. No issues were noted at this time. Facility conducts quarterly disaster drill. Last drill was conducted on 5/21/25. Last fire inspection report was conducted on 3/7/24 to include tests on all manual pull stations and smoke detectors. Per report, test results passed. Facility has a dementia and infection control plan. Administrator provided the following documents during this visit: current Liability Insurance Certificate, LIC500 and LIC308 to the Department. No deficiencies are being cited at this time. Exit interview was conducted and a copy of this report were provided. {2 of 2}