Routine inspection·February 20, 2025

Unannounced annual visit made out to this facility on 02/20/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, James Hall, who was briefly interviewed at this time. It was learned that there were (4) residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (10) residents at any given time. It was learned that there were (14) residents diagnosed with dementia at this time. This facility does have an approved program to be able to accept and retain residents diagnosed with dementia at any given time. This facility does have a memory care unit on site at this time. Current census was 54 residents for both the Assisted Living and Memory Care portions of this entire facility. Tour of the facility was conducted. A tour of the facility kitchen area was conducted. Food storage units, refrigerator and freezer, were toured. It was observed that there was a sufficient supply of 2-day perishable food quantities available on site to meet the requirements at this time. Pantry area was toured. It was observed that there was a sufficient supply of 7-day nonperishable food quantities available on site to meet the requirements at this time. A sample review was conducted for the facility resident bedrooms at this time. It was observed that furniture and furnishings were observed to be functional and maintained in compliance at this time. A sample review was conducted for the facility resident restrooms at this time. Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times. Grab bars and non skid surfaces were observed to be present and maintained in compliance at this time. Living areas, dining areas, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Laundry rooms, located throughout several wings of this facility on the first floor, were toured. They were observed to be unlocked but did not house any detergents, bleach, or cleaning supplies at this time. Rooms designated as supply rooms, storage rooms, and equipment rooms were observed to be locked and made inaccessible to the residents at this time. Exercise room was toured. Equipment and supplies were observed to be sufficient and able to meet the needs of the residents at this time. Medication room was toured alongside the facility nurse, Karen Silva, at this time. Policies and procedures in regards to the handling, dispensing, and documentation of the resident medications were discussed with her at this time. This facility utilized mobile medication carts that were pushed out into the facility when it was time to dispense the medications to the residents. It was learned that this facility employed an E-MAR system as well as documented paperwork for the facility resident medications at this time. First aid kit, located in the medication room, was observed to contain all of the required components at this time. Fire extinguishers, located throughout this facility, were observed to have been annually inspected by the local fire extinguisher company, Johnson Controls, on 02/27/2024 and found to be in compliance at this time. A tour of the facility exterior grounds was conducted. A review of the perimeter fence, side gates, and all other exits was conducted at this time. A review of (7) facility resident files was conducted and noted on the following LIC 858. A review of (7) facility personnel files was conducted and noted on the following LIC 859. The following forms and documents were requested by this LPA to be updated and submitted into CCL: LIC 308 LIC 400 LIC 500 LIC 610 The following deficiencies were observed and cited on the following LIC 809-D 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