Routine inspection·March 28, 2025

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by concierge Caroline Fitzgerald. LPA discussed the purpose of the visit with Administrator’s Izzy Perez and Michelle Neumann and Kaitlyn Collins, Director of Resident and Family Services (DRFS). According to the facility’s license, there may be a maximum of 122 residents all of whom may be non-ambulatory in at any given time at the facility site with an approval waiver of 25 residents on hospice. Facility is approved for delayed egress and secured locked perimeters. During today’s inspection, the facility’s current census is 68 residents living at the facility. There were 68 residents present at the facility site during the inspection. LPA, accompanied by Administrator Neumann, DRFS Collins and Josue Lopez Director of Plant Operations, toured the interior and exterior of the facility, and inspected residents’ room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required linens and furnishings. Doors, windows, toilets, and showers were all in working order. Extra linens and hygiene supplies are kept in the caregiver linen closet. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities. The facility’s ambient internal temperature was comfortable and compliant, at 74 degrees Fahrenheit (F). Hot water temperature at taps accessible to residents were compliant: In the Nexus Community, hot water temperature in a random room measured 108 degrees F; kitchen sink measured hot water at 107.8 degrees F; [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] In the Springs Community, hot water temperature in a random room measured at 111.9 degrees F; community sink measured hot water at 109.9 degrees F; the Pacifica Community, a random room measured hot water at 110.5 degrees F; community sink measured hot water at 112.8 degrees F; the Bluffs Community, a random room measured hot water at 111.7 degrees F; random room #2 measured hot water at 110.8 degrees F; and community kitchen measured hot water at 115.2 degrees F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present in their main kitchen. Cooking, dining equipment and utensils were present, and all safely stored in their storage area. There were no toxic chemicals or poisons accessible to residents. Medications were properly labeled, as required, and stored in their locked Wellness Centers. LPA inspected the medication room and found that medications were properly labeled and stored in a locked cart in their locked Wellness Center. The facility-maintained medication logs which LPA reviewed. The facility did have a pool area that measured up to 4 feet in depth. There was a locked gate that is in good repair which surrounded the pool. The fence was designed and installed to be unremovable and measured more than 5 feet high. The fence was not obscured from sight and there was no door or window which could access the pool area. The openings from the railings did not exceed 4”. The bottom from the ground to the hard surface of the fence did not exceed 2”. No ladder was observed near the vicinity of the pool and the platform is completely in accessible. The fence was thick enough that it could not be easily broken, removed or stretched. Administrator agreed that the fencing will remain in place and properly functioning whenever there are licensed residents in care. Administrator also agreed that ladders will remain inaccessible whenever there are licensed residents in care. Per Administrator Neumann, no firearms or ammunition are kept at the facility. Carbon monoxide detectors and fire alarms are yearly inspected by their Fire Department and was last inspected on March 10, 2025. Fire extinguishers were present (26) and serviced within the last 12 months. First aid kits were complete and readily accessible in their Wellness Centers. Emergency lighting and facility telephone were all working. LPA interviewed staff and residents, and reviewed staff and resident records. LPA interviews, with staff and residents, did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility. [CONTINUED ON LIC 809-C] [Continued from LIC 809-C] It should be noted that the inspection was interrupted for approximately one hour for a lunch break and resumed promptly at 1PM. During today's visit, there were no deficiencies observed or cited during the annual inspection. An exit interview was conducted with Administrator Michelle Neumann, Kaitlyn Collins, Director of Resident and Family Services, Keirstin Rodman, Clinical Staff and Office Manager, Kathy Roney, Culinary Director, and Cindy Blenkarn, Director of Health Services. A copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided to Administrator Neumann, at the conclusion of the visit. The signature below confirms the documents were received. LPA received their updated Plan of Operations to include the updated regulations for RCFE and Dementia. LPA requested Administrator Neumann to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, and Emergency Disaster Plan LIC 610-E to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov .