Routine inspection·April 6, 2026

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 10:00 a.m. Upon arrival LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Executive Director (ED) Ramon Pagels and reason for the visit was explained. Entrance interview. Starting at 10:40 a.m. the LPA and ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: The facility is a three-story building that consists of a secured memory care unit on the second floor and an assisted living unit. The facility is fire cleared for a capacity of 207 residents age 60 and over of which all may be non- ambulatory. Dementia wing rooms 240 to 258 approved for delayed egress. Hospice waiver for ten (10). LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 01/02/2026. LPA observed all the required postings in the Mail Room near the entrance and throughout the facility. The facility maintained a comfortable temperature throughout the visit. Common Areas: This includes the mail room, living room. library, bistro, dining room, private dining room, activity room, theater, fitness center, salon, technology center, wellness center and laundry rooms. Each floor has its own laundry room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Fireplaces were properly screened. Facility elevators were operating properly. There are five (5) stairwells that all have emergency evacuation chairs on the third floor. Report Continued on LIC 809-C PAGE 2 ... (PAGE 2) Report Continued from LIC 809-C... Surrounding Grounds (Outdoors) : The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors. LPA observed the facility generator adjacent to the entrance of the facility. LPA observed the facility main water and gas shut offs. LPA observed the designated smoking area, along with a putting green. Delayed egress doors checked and were operable at the time of visit. Activities: Planned activities are offered, and the activity schedule was posted, and is provided to the residents on a weekly basis. Activity rooms and common spaces appeared clean and in good repair. LPA observed residents engaged in both the Assisted living and in Memory care. Kitchen : The kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. The menu was posted and copies are available for residents. The menu is reviewed regularly by a dietician with the last review on 10/09/2025. The facility offers daily specials and a standard selection at every meal. Appliances appeared to be in operable condition. Snacks and beverages are available for residents in the Bistro. Knives are stored and inaccessible to residents. Refrigerator and food pantry were checked for proper labels and expiration dates. Bedrooms: There are one hundred thirty six (136) total apartments in the facility, one hundred seventeen (117) assisted living and nineteen (19) in memory care. There are resident rooms on all three (3) floors, units are designated for assisted living residents on all three (3) floors and a separate unit on the second floor is designated for residents in the memory care unit. There were no obstructions and/or tripping hazards observed. LPA observed sixteen (16) randomly selected resident bedrooms, of which twelve (12) in assisted living and four (4) in memory care. All resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. All passageways were observed to be clear of obstructions. Report Continued on LIC 809-C (PAGE 3) Report Continued from LIC 809-C PAGE 2... Restrooms: LPA observed resident restrooms along with common / community restrooms. Resident restrooms appeared clean, sanitary and in operating condition with grab bars and to be equipped with a slip resistant surface / mat. The restrooms were sufficiently stocked with supplies and paper towels. Towels and washcloths are not shared among the rooms. The hot water temperature was measured and ranged between 110.2 - 115.2 degrees Fahrenheit all within the required range. Medication Audit: There are two (2) medication rooms / wellness centers in the facility. One on the first floor for assisted living and one on the second floor for memory care unit. Med Techs distribute medication at the appropriate times to residents in care. Medication audit for ten (10) residents was conducted. Eight (8) in the Assisted Living Unit and two (2) in the Memory Care Unit. The following was observed. The medications were stored in the medication rooms in carts, both were locked and inaccessible to the residents. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed. During the medication review LPA observed four (4) out of ten (10) along with other residents with start dates missing on the centrally stored medication and destruction record. LPA advised Med Techs the importance of proper documentation to ensure medication audit and count it correct. Med Tech and supervisor agreed to conduct an internal audit to ensure all records have the start date document on the centrally stored medication and destruction record. DOCUMENTS: Documents obtained during the visit include: Staff roster and a Resident roster. Due to time constraints the LPA will return to complete the annual at a later date. Exit interview conducted. Copy of report reviewed and provided.