Routine inspection (multi-day)·March 6, 2025

At approximately 9:40AM, Licensing Program Analysts (LPAs) Hansen and Contreras arrived unannounced to continue a 1 Year Required Visit, and met with Business Office Director (BOD), Tony Ibarra & Ieshaa Ragland, Health and Wellness Director (HWD) as Administrator, Morgan Whinery was not available. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Upon arrival, LPAs were informed that there were 118 residents in Assisted Living and 60 in Memory Care for a total of 178 residents in care. LPAs were also informed that there were 43 staff members on-site. On 3/6/2025 at approximately 9:45 am LPAs conducted a sample review of ten residents & ten staff records. LPAs reviewed resident’s files and learned that 10 out of 10 residents have an updated reappraisal/needs & care plan on file as well as medical assessments at this time and were all found to be well organized, thorough and contained the required documentation as required by Title 22 Regulation. During staff file review, LPAs observed that 10 of 10 personal files were not readily available for review (see LIC809D). CCL will return to review files at a later date. LPAs followed up on incident report that was self-submitted to Community Care Licensing (CCL). Incident Report : CCL received an incident report from the facility on 03/05/2025. Report states that on 03/03/2025, at aprox 2:45pm staff noticed facility alarm door 1 on floor 2 was unarmed when conducting routine door checks, head count conducted finding R1 missing. Facility conducted search, informed law enforcement & family. R1 was found 2 hours later at 4:45pm by law enforcement and returned to facility by law enforcement, after assessment, no injuries noted. Review of R1's physician's report and care plan indicates they are unable to leave unassisted and has a dementia diagnosis (deficiency cited, see LIC809D, Regulation 87705(b)(2). LPAs are requesting the following documents to update facility file: Continue on LIC809-C Continued from LIC809 Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Updated Liability Insurance Active and Current Administrator Certificate Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 03/21/2025. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..