Routine inspection·October 8, 2025

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Upon arrival, LPA was greeted by Therese Brown, Senior Director of Health Services and explained the purpose of the visit. Executive Director Brian McCague participated in the inspection. The facility is a Continuing Care Retirement Community (CCRC) that consists of Independent Living, Assisted Living, and Memory/Dementia Care. The facility is licensed for a capacity of 360 residents of which there can be 144 non-ambulatory residents and a hospice waiver for six (6) residents. There are zero (0) residents currently on hospice. Entrance interview conducted. LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors, and floor coverings throughout the facility were checked. The facility was seen to be in good repair inside and outside. LPA observed eight (8) fire extinguishers last serviced on 5/21/2025. There is a fire pull alarm system with pull alarms throughout the facility. The pull alarms ring directly to the local fire department. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. At approximately 12:20 pm, LPA conducted a tour of the facility’s dining areas. LPA observed The Grill, an eatery consisting of patio seating, indoor/outdoor seating, and barista style seating. Lunch and dinner are served Wednesday through Sunday. The Grill’s dining capacity is 80. Please continue to 809-C, Pg 2. LPA observed the main dining room includes indoor seating and an outdoor dining area. Breakfast is served in the formal dining area seven days/week including a morning brunch one day/week, lunch is served two days/week including the morning brunch one/day/week; and dinner is served six evenings/week. The facility’s dining services also include a “Take-Out Buffet” which consists of “grab and go” seven days/week from 7:30 am through 6 pm. Director of Dining Services stated the facility receives food deliveries each day of the week. LPA observed a sufficient amount of perishables for two days and seven days of non-perishables. Each level of care has its own activity calendar although residents from all levels are welcome to participate in all activities. Activities include outings to parks, restaurants, museums, theaters, scenic drives, sports activities, and other local attractions. The Life Enrichment program covers the seven dimensions of wellness including spiritual, physical, emotional, vocational, intellectual, social, and financial topics. The facility maintains a close relationship with local music and art organizations aimed to enhance the residents’ experience. Residents have access to an in-house television station that includes documentaries, self-help programs, movies, and guest speakers. Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Medication Administration Records (MARs). On 9/17/2025, CCLD received LIC624 Unusual Incident/Serious Injury Report stating on 9/15/2025, Resident 1 (R1) was administered the wrong medication during the morning medication pass. The incident report states Staff 1 (S1) handed R1 the wrong medication container containing four (4) medications. The incident report states R1 “self-administered medications” before S1 was able to intervene. The incident report states S1 completed additional training on proper medication administration. S1 was scheduled for oversight medication pass by Staff 2 (S2), however S1 decided to return to their previous role and decided not to resume a role to include medication administration. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D). Due to time restraints, LPA will return at a later date to continue the inspection. Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.