Routine inspection·June 5, 2025

Licensing Program Analysts (LPAs) Holly Williams and Charlie Yang arrived unannounced to conduct an annual inspection. Conducted a brief interview on the phone with facility designated administrator (FDA) Brandon Collins. LPA Williams reviewed 8 resident files (R1-R8) and eight staff files (S1-S8). S7 did not have a Tuberculosis test in their chart. LPA Williams toured the facility with Brittany Ragan and inspected common areas, the kitchen, bedrooms, bathrooms, and court yard areas. Furniture and furnishings were sufficient to meet the needs of residents. LPA observed outside of memory care a gate that is broken at the bottom and is sharp. S7's bed is broken at the foot of the bed and is sharp to the touch. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 111 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Williams observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Williams observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Williams observed the locked medication room and conducted a review of the narcotics log for 5 residents. Staff members counted out the pills and all 5 resident logs were correct. LPA observed cabinets that are locked for the storage of medication. LPA Williams observed locked cabinets for the storage of cleaning solutions and knives. In memory care the laundry room was unlocked and detergent was accessible to residents. LPA observed a cockroach in the shower on the floor. [Continued on 809-C] LPA Williams interviewed four staff members (S5-S9) and five residents (R8-R12). The following deficiencies were observed and cited on the following LIC 809D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal rights were printed and a copy was given to the facility designated administrator at this time. Exit Interview