Routine inspection·October 10, 2025

At approximately 8:55 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a 1-Year Required inspection. LPA was greeted by Administrator, Anne Nakiyuka at 8:40 AM. Enso Village, a Kendal Affiliate serves older adults in Independent living, Assisted Living and Memory Care. The facility is licensed as a Residential Care Facility for the Elderly-Continuing Care Retirement Community (RCFE-CCRC). The Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for four hundred (400) non-ambulatory residents. The facility has an approved hospice waiver for ten (10) residents. The facility consists of multiple buildings, all of which are inter-connected by paved walkways. LPA was informed that there were 307 Residents in care. At approximately 10:30 AM LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 11:00 AM LPA toured the facility with Administrator Nakiyuka. The facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. All common areas, hallways, and bathrooms observed by the LPA had sufficient lighting. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing/showering as needed. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility offers a wide variety of menu options for the residents at each meal. There is a main dining room and a smaller dinning room available for assisted living residents. There is also a separate kitchen offering strictly vegetarian and vegan options for residents. Snacks are available to residents at all times. The Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. All toxins/cleaners were locked and inaccessible to residents in care. Hot water temperatures for a sample size of fifteen (15) sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. All stairwells had evacuation chairs per regulation. Continued on 809-C... ...Continued from 809 The buildings' smoke and carbon monoxide detectors and sprinkler system were last inspected in 5/2025. All exits were observed to be unobstructed. All fire extinguishers were serviced and tagged in 8/2025. The facility conducts disaster drills quarterly. The last disaster drill was conducted on 8/14/2025. LPA also followed up on an incident report that was submitted to Community Care Licensing (CCL) by the facility. The Incident report stated that a Memory Care resident (R1) was found walking outside of the Memory Care unit. The delayed egress door alarm where the resident exited the memory care unit was not functioning. The facility will be cited for the delayed egress door alarm not functioning. The facility had the door repaired immediately. The facility has begun checking the delayed egress door alarms twice a day and has begun keeping logs of the delayed egress alarm tests. It addition, the facility has added alarms to each door so that facility security and staff are alerted when the alarm is activated. As such, the deficiency has been cleared during today's visit. LPA was unable to complete the Annual Inspection. An Annual Inspection Continuation Visit to be conducted at a later date. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, 811 Confidential Names, Letter of Deficiency Clearance and Appeal Rights discussed and provided to Administrator Nakiyuka. Signature on form confirms receipt of documents.