Routine inspection·January 15, 2026

Licensing Program Analysts (LPA'S) Kesha Lewis and Kimberly Viarella arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA'S were met by administrator. LPA'S explained the purpose of the visit to Administrator. LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 136 bed facility with a current census of 73. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care. LPA also conducted the care tool. No bodies of water were observed at the facility. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings. LPA’S observed the laundry room in memory care to be malodorous, additionally the facility was missing several window and sliding door screens. A patch of ceiling was falling in memory care. LPA'S observed there to be missing base boards on the assisted living side. Gutters along the building had plants growing from them and a gutter on the side of the facility was broken. LPA'S observed the housekeeping supply room to be left unlocked and accessible to residents in care. LPA'S tested the water temperature in resident room 37 and found the water temperature to be above regulation at 149 degrees Fahrenheit in resident bathroom sink. LPA Viarella conducted an inspection of the medication rooms. LPA reviewed the centrally stored medication log and observed a sample count of narcotics to ensure it matched with recorded amounts. LPA also inspected the medication cart and pulled a sample of 5 medications to ensure that none had expired. All were in compliance at this time of this inspection. LPA and the medication technician on duty reviewed medications through the Electronic Medication Administration Record (EMAR) to ensure that all medication passes were in compliance. LPA also reviewed the first aid kit to insure that it contained all of the required elements at the time of this inspection. LPA observed, fire extinguishers inspected on 09/15/2025 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance. See 809 C LPA reviewed four (4) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA reviewed eight (8) resident facility files, four (4) memory care and four (4) Assisted living. COVID-19 Plan, and survey binder. All necessary documents were in place. Exit interview held with staff and copies of reports and appeal rights left at conclusion of visit.