Routine inspection·May 21, 2025

On May 21, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. LPA met with the Executive Director (ED), Li Li, and disclosed the purpose of the inspection. The facility consisted of two buildings with three floors each. First building was a combination of two assisted living units (elite care and assisted living), and two memory care units (meadow wing and focused care). The second building was for independent living. The ED informed the LPA that the facility had 179 residents in care at the time, including 93 in Assisted Living, 38 in memory care, and 48 in Independent Living. At 9:45 AM, LPA initiated a walk-through of the facility, accompanied by the ED. LPA inspected randomly selected ten (10) resident rooms in Assisted Living and Memory Care units. The rooms were found to be clean, well-lit, and equipped with the required furniture. Emergency pull cords were observed to be functioning in the resident rooms with an average response time of 5 minutes. LPA inspected the private bathrooms in these random rooms. The bathrooms contained soap, grab bars, towels, a trash can, and non-slip flooring. The hot water temperature at the sink faucets measured between 114.6°F and 116.8°F. “Oxygen in Use” signs were observed posted outside the residents’ room where oxygen was administered. LPA inspected the main kitchen and found it clean. The refrigerator, freezer, and pantry cabinets were checked, and there was a sufficient supply of fresh perishable food for two (2) days and nonperishable staples for seven (7) days. No expired food items were found. Open food items were wrapped and dated. The dining rooms in Assisted Living and Memory Care were inspected and were found to be clean, with all furniture in good repair. Continued on LIC809-C LPA inspected activity areas, library, media room, great room, fitness center, and other commons areas and observed residents actively engaged in recreational programs and activities. Activity calendar was observed posted at various locations throughout the facility. All common areas were free from obstructions, and hallways were well-lit. LPA inspected locked laundry stations on each floor and observed working washer and dryer units. Sharp objects, detergents, and chemicals were observed to be locked and inaccessible to persons in care. LPA inspected the fire extinguishers mounted on the hallway walls in Assisted Living and Memory Care and found them fully charged, with the last service tag dated 12/24/2024. The smoke detectors are tested semi-annually by a third-party vendor, Performance Systems Integrated with the last inspection completed on 03/11/2025. A staff member tested the carbon monoxide detector in the basement garage in LPA’s presence, and it was found to be functional. LPA toured the outside courtyard and patio areas and found passageways in good condition, free of obstructions, and without any blocking or tripping hazards. These areas had patio tables, chairs, and umbrellas for residents’ use. Delayed egress was observed on emergency exits and exterior exit doors were locked. No accessible bodies of water or hazards were observed. LPA reviewed six (6) staff personnel records and five (5) resident records. The LPA observed that 5 of 5 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 6 of 6 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 6 of 6 staff members were associated with the facility. LPA observed locked centrally stored medication carts in the Assisted Living and Memory Care units. Medications were organized separately for each resident. Narcotics were locked and the count was correct. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete. LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster (Fire and Earthquake) Drills were conducted monthly, with the most recent drill completed on 05/15/2025. The following updated forms are requested to be submitted to CCL by 05/28/2025: Continued on LIC809-C LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility Certificate of Liability Insurance Administrator Certificate(s) No deficiencies were cited during today's visit. An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Li Li, whose signature on this form confirms receipt of the report.