Routine inspection·January 23, 2026

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Required 1 Year visit and met with Executive Director (ED)/Administrator, Patricia Gustin. Required postings observed. There are eight residents receiving hospice care services within the approved hospice waiver. Facility has an approved dementia care plan. LPA obtained staff schedules for the Assisted Living and Memory Care Units for the month of January 2026 with a census of 98 residents in care indicates that the facility had an average of two caregivers on duty for residents in care and one medication technician (med-tech). Currently, there are currently 76 residents in Assisted Living area and 22 residents in Memory Care Unit. LPA/ED observed three caregivers present in memory care, one resident care coordinator and one med-tech. There are two caregivers present in assisted living area and one med-tech, there is one caregiver present who alternates between assisted living and memory care unit to assist with showers and incontinence care. LPA/ED toured the facility which included an inspection of assisted living and memory care, all common areas, hallways, and bathrooms observed had sufficient lighting. Residents rooms are furnished per regulation. Facility's Memory Care is allocated to one floor. The facility was a comfortable temperature. Passageways were free of obstructions. Cleaning products are in locked closets or on supervised and/or locked carts. Facility has a sufficient supply of cleaners, hygiene items and paper products. Multiple first aid kits were observed. A call button is located in each bathroom, LPA tested the call system in resident's rooms and staff response time was under three minutes. Continued on LIC 809-C.. Continued from LIC809... LPA/ED observed the memory care unit is on a delayed egress system, which it was approved in their fire clearance. The units two delayed egress doors were tested. There are evacuation chairs located at each stair. The elevators were last inspected on 7/16/25 and permit expires on 7/16/26. The facility has a generator in case of any power outages. The last fire drill was conducted 12/26/25. Fire extinguishers were observed to be last charged on February 2025. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected 3/26/25 & 10/3/25. At approximately 10:25am, LPA/ED toured the kitchen area located in the second floor of the building. A tour and inspection of the kitchens and dining areas were found to be clean and sanitary except a cart containing dirty dishes had a bottle of disinfectant cleaner (technical advisory issued). Also, there were two prepared left over fruit cups and tray containing at least 38 pieces of food were observed uncover and not labeled. Per kitchen chef, the left over cups were going to be discarded and tray of food was ready to be fried, but the stove was not on. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. Refrigerators and freezers were at required temperatures. Menu includes a wide variety of foods from all of the food groups. A board in the kitchen has written instructions for residents with food allergies and restricted diets. Other cleaning products and medication carts that were observed on the floor were supervised and/or locked carts. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. During the tour, residents were observed participating in group activities in common areas. There are activities written on a board specified for both assisted living and memory care engagement. Water temperatures measured at between 107.3 and 112.1 degrees (F) which is within acceptable range of 105 to 120 degrees F. Bathrooms have non-skid surfaces and grab bars at the toilet and showers. Additionally, LPA/ED noticed that garbage cans located in some resident's bathrooms do not have lids, LPA had a conversation with ED regarding the importance of providing garbage cans with well-fit covers (technical advisory issued). Continued on LIC809C... Continued from LIC809C... At approximately 11:14am, During the walk through of the six story building including assisted living and memory care, LPA/ED observed two resident's toilets were observed dirty, one located in the assisted living and one located in the memory care unit. Based on records review, the facility provided housekeeping schedule for the month of January 2026 for both areas, which indicates that room in assisted living area is scheduled to be cleaned two times per week (Sunday & Wednesday), unless that residents call to get assistance to clean their bathroom, the staff won't come to do so, which it was agreed and signed in their admission agreement. Regarding memory care area room, the housekeeping schedule revealed that the dirty toilet should have been cleaned today by 10am. According to ED, the housekeeping staff designated to memory care area called in sick this morning, and they were expecting another staff to come and cover for them. - At 11:30 AM, LPA conducted a file review of six staff and ten residents. Residents receiving hospice services had a care plan that appears to be accurate to services being provided. All residents' care plans seems to have a person-centered approach and they are updated. Medical assessments are current and included a description of any known behavioral expression. One out of six (S1) staff did not have a current CPR/1st aid on file. According to ED, staff recently was hired as a housekeeper and they are in the process of training S1 as caregiver (Technical advisory was issued). All staff have required training hours complete. Patricia Gustin, administrator certificate 7010392740 expires on 6/8/2027. Medications and medication records were reviewed. Annual fees are current. ED agrees to submit updated documents by 2/6/26: (LIC500) Personnel Report & Liability Insurance. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties . Exit interview conducted with ED/Administrator and copy of report was given.