Non-compliance follow-up·February 24, 2026

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management – legal/non-compliance visit. LPA met with General Manager (GM), Billy Mitchell. The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) office at a non-compliance meeting held on June 13, 2024. During visit, LPA toured the facility with staff to include Garden House ( memory care unit), Plaza, common areas. There are 2 Med Techs and 4 caregivers in Assist Living for AM shift and PM shift. There are 4 caregivres and 1 Med Tech for Memory Care unit for AM shift and PM shift. LPA reviewed the facility's roster and observed the 11 staff members are associated to the facility. In Garden House, LPA randomly entered into rooms #101A, #100, #102A, #101B, #103, #104 and #106A with GM. All the cabinets observed secured. No observation of accessible sharp objects, chemicals, disinfectants, and hygiene products to residents in care with dementia. In Plaza, LPA randomly entered into rooms #227, #226, #225, #223, #222, $216, #214 with GM. No issues were noted. Residents who store their own chemicals, disinfectants and hygiene products are able to store these items per their physician's report/records. Continue on LIC809-C. Page 1 of 2. LPA observed all training topics stated on the non-compliance plan was completed with signature log - fall policy; resident rights, toxic chemicals, and fire & alarms; and change of condition and mandated reporting. 5 random resident files were reviewed and observed complete. 5 resident files contained a signed personal rights form, updated physician’s report, and a signed updated appraisal/needs and services plan. 5 random staff files were reviewed. 5 staff are fingerprint cleared and associated to the facility. LPA advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation. GM was reminded of the discussion on June 13, 2024 of the facility being under monitoring inspection visits to ensure compliance with the compliance plan and Title 22 Regulations for 2 years. No deficiencies were cited today. This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided.