Routine inspection·August 26, 2025

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Administrator Jade Alma was present at the time of arrival. There were 48 residents in care in the Assisted Living unit with 1 medication technician, 2 caregivers from home health agencies on duty. Resident Services Director was also on duty. In the “Compass Rose” Memory Care unit, there were 16 residents with 1 medication technician and 2 caregivers on duty. The Compass Rose Coordinator who currently oversees the activity programming for the Memory Care unit of the facility was also on duty. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to residents with a dementia diagnosis, and 99 non-ambulatory residents of which 10 may be bedridden. There are 11 residents currently on hospice. Entrance interview conducted: The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. Throughout the facility, there are approximately 14 fire extinguishers and 5 fire pull alarms. The pull alarms alert the local fire department when activated. Fire inspection was most recently conducted on 5/20/2025. LPA observed the dining areas are clean. LPA observed kitchen cabinets, refrigerator, stove, and counters are clean. Please continue to 809-C, Pg 2. Assisted Living Residents participate in activities such as special occasion celebrations, music entertainment, Bocce ball, physical therapy, and excursions to local eateries and retail businesses. Memory Care residents participate in activities such as special occasion celebrations, music entertainment, and scenic drives. A "Cycling without Age" activity is available for residents in Assisted Living and Memory Care. At approximately 2:19 pm, LPA reviewed medication records and incident reports. On 6/19/2025, the facility self-reported an incident that occurred on 6/15/2025 wherein at approximately 5:50 am, Resident 1 (R1) was administered their first dose Hydromorphone 2mg. At approximately 6:00 am, Staff 1 (S1) administered a second dose of Hydromorphone 2mg to R1 in error. Administrator stated they were trying to obtain additional information as to how the error happened, however S1 did not report to work after the incident and therefore the administrator was unable to determine how or why the incident occurred. Administrator stated most likely S1 did not review the Electronic Medication Administration Record (EMAR) or the Narcotics book before administering the second dose to R1 and if S1 had reviewed the records, S1 would have seen the medication had been administered about 10 minutes before the second dose was administered. Administrator further stated although the incident report states S1 was administered corrective counseling and re-training of medication administration, S1 ‘terminated’ themselves before further investigation and re-training could be conducted. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Due to time restraints, LPA will continue the annual inspection at a later date. Exit interview conducted. Copy of report issued at the time of the visit.