Routine inspection·June 4, 2025

Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct an Annual Required - 1 Year inspection, at approximately 9:45am on 6/4/25, and met with Administrator Megan Leone. LPA toured the facility, assisted living (AL) main building, and the memory care (MC) building, with administration staff, Megan Leone, Administrator/ED, Joel Gonzalez, Business Office Director (BOD), and Michelle Simpson, Health Services Director. Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has a plan of operation for dementia care. The facility has a hospice waiver approval for ten (10) residents. Fire clearance is approved for one hundred and seventy-three non-ambulatory, of which 16 may be bedridden. Capacity breakdown as follows: AL main building, and the five (5) bungalows are cleared for one hundred and forty (140) non-ambulatory, of which six (6) may be bedridden, the MC building is cleared for thirty-three (33) non-ambulatory, of which ten (10) may be bedridden; Total license capacity is one hundred and seventy-three (173) . The delayed egress is approved, per fire clearance. Per review of the emergency disaster drills binder, the facility is completing quarterly drills as required.All exits were clear and unobstructed. Facility fire extinguishers were serviced and tagged as required. All stairwells, four (4) in AL, and one (1) in MC, all had the required emergency evacuation chair, including all had instructions on use posted up. LPA reviewed ten (10) resident files, including medications, and medication records were reviewed. LPA reviewed ten (10) staff files. All staff had required criminal record clearance. All staff have required training. Facility has sufficient supply of perishable and non-perishable food. Freezer and refrigerator was observed to be orderly, and within required temperature (s). Continued on LIC809C... Facility had sufficient supply of the following: cleaners/disinfectants, paper products, soaps, sanitizer, and personal protective equipment (PPE). Facility had sufficient lighting throughout the facility, in observed common areas, hallways, and bathrooms. Facility was at a comfortable temperature during the inspection. Facility had emergency supplies as required; Facility had supplies to meet the requirements of "72 hours- Shelter in Place". LPA is requesting the following documents be updated and submitted by 7/4/25: LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required -if no changes, submit the last page with date/signature of review) Infection Control Plan (ensure to review and update as needed/required -if no changes, submit the last page with date/signature of review) Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed Copy of Current Liability Insurance Copy of Administrator Certificate Updated LIC500 Personnel Report LIC308 - Designation of Administrator Responsibility The following observed deficiencies will be cited: LPA observed with the administration staff during the memory care tour that a resident's, R1, room smelled strongly of urine, observing the room to be in need of a deep cleaning to ensure "facility is free from incontinent odors" as required by regulation; Managed Incontinence 87625(b)(3)- Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence, see LIC809D. LPA observed with the administration staff during the memory care tour that resident’s, R1, room had blinds hanging on their windows that were broken and some pieces missing; LPA observed the blinds hanging on the window in joint/shared private sitting area right outside of R1's room to be in the same condition as their room blinds. 87303(a) Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors, see LIC809D. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with the Administrator/ED Megan Leone. Appeal Rights Provided to the Administrator/ED.