Routine inspection·May 27, 2025

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual Inspection of facility and was welcomed by Business Office Mgr. Elizabeth Alfaro, and met with Administrator, John Beltz. Facility is 2 stories and contains both assisted living and two memory care units. There are 43 Assisted Living Apartments and a total of 32 memory care apartments. Facility has approved fire clearance from Petaluma Fire Department for 80 Non ambulatory & 15 Bedridden residents from 5/16/2023. Hospice Waver approved for 12. Facility currently has 44 Assisted Living residents and 39 residents in memory care. Also, there are 7 residents currently receiving Hospice. Facility tour/inspection began at 8:40 AM: LPA toured the facility on 5/27/2025 with Executive Director John Beltz; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The facility has a special care plan of operation and programming for residents with dementia. Fire Extinguisher was found to be last charged on 10/20/2024. Facility smoke detectors with combination carbon monoxide detectors are hard wired and sound directly to the fire station. Smoke/carbon monoxide detectors (last inspection 10/20/2024) and fire sprinklers are inspected annually, and inspection records are current with the last inspection being conducted on 4/15/2025. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 108.8 degrees F and 120.9 degrees F falling out of Title 22 acceptable regulation of 105 F to 120 degrees F in 2 of 9 resident’s bathroom faucets, boiler was turned down at visit (LIC9102 TA). There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Menus are available and provided during meals. Continue on LIC 809-C Continued from LIC809 LPA observed that provisions are made for individuals with special dietary needs; facility keeps a variety of items on the menu, and facility has a board in the kitchen with a picture of the resident & a list of dietary needs. Food is available for residents any time of the day. There is a daily activity schedule for residents posted. Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with towels and hand soap dispensers when a private room. Resident bathrooms had required slip resistant mats and grab bars. A sample tour of nine resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. File Review began at 11:45 AM: A sample review of nine residents & six staff records as well as four resident’s medications was conducted. LPA learned that 9 out of 9 residents have an updated reappraisal/needs & care plan as well as medical assessments. As per sample review of staff records, staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. All direct care staff files reviewed have completed annual required trainings; 2 out of 5 direct care staff (S1 & S2) files reviewed did not obtain required proof of 1 st Aid certification (see LIC 809-D). Medication Audit began at 1:30 PM: Medications were centrally stored in (5) locked medication carts and in the facility medication room at the facility. LPA observed medications of 4 out of 4 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 4 out of 4 residents were found to have all medications entered for residents. Facility uses bubble pack and pharmacy CSMR for all residents at the facility. Emergency Disaster Plan reviewed with Administrator. Disaster Drills have been conducted monthly and in different shifts with the last one being conducted on 4/28/2025. In addition, John Beltz, Administrator Certificate # 7017264740 expires 9/30/2026. Continue on LIC809-C2 Continued from LIC809-C1 Appeal of Rights Given. 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. LPA Hansen is requesting Administrator to update the following documents and to submit to CCL by 6/20/2025: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (if changed) LIC 9020 Register of Facility Resident’s (already received) Copy of Control of Property-Deed or Lease Copy of Administrator Certificate Copy of Certificate of Liability Insurance