Routine inspection (multi-day)·April 8, 2026

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility to conduct an unannounced continuation of the annual inspection that began on April 06, 2026 (04/06/2026). 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 the reason for the visit was explained. Entrance interview. During the annual inspection conducted on 04/06/2026, LPA Mosley completed a comprehensive physical plant tour. The tour included, but was not limited to, the common areas such as the mail room, living room, library, bistro, dining room, private dining room, activity room, theater, fitness center, salon, technology center, wellness center, laundry rooms, kitchen, and surrounding outdoor grounds. LPA also observed ongoing activities at the time of the visit. LPA Mosley inspected sixteen (16) randomly selected resident bedrooms, twelve (12) located in assisted living and four (4) in memory care, as well as resident restrooms and common/community restrooms. Additionally, LPA conducted a medication audit and obtained pertinent documentation. During today’s visit, starting at 10:15 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns, 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 and are inspected monthly by facility staff. Report Continued on LIC 809-C PAGE 2 ... (PAGE 2) Report Continued from LIC 809-C... Records: Personnel Records were reviewed beginning at 11:13 a.m. Ten (10) Personnel files including the ED's file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. Resident Records were reviewed beginning at 12:42 p.m. Ten (10) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, Home Health records, Hospice records, PRN authorization letters, and current needs and services plan. All records were in order. Facility Records: The facility uses Johnson Controls to conduct their annual fire alarm system inspection that was conducted on 04/03/2026 indicating a pass. LPA reviewed the quarterly inspections, testing and maintenance reports for the wet pipe and fire sprinkler system conducted on 03/04/2025, 05/27/2025, 08/25/2025 and 12/03/2025 indicating a pass in all areas. LPA reviewed smoke detector monthly test conducted the month of February 2026. The daily vehicle inspections, and annual Inspection report for both facility vehicles were reviewed. All records were in order. Infection Control / Emergency disaster planning: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The emergency disaster plan was observed to be updated and reviewed on 02/24/2026. The last emergency disaster drill took place on 03/28/2026 at 12:30 a.m. and conducted quarterly covering all shifts and areas of emergency disasters. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard. Interviews: During the initial visit on 04/06/26 and throughout today’s visit, LPA Mosley conducted brief resident and staff interviews. LPA interviewed nine (9) staff members, who demonstrated knowledge of resident rights, the various forms of abuse, and appropriate reporting procedures. LPA also conducted eleven (11) resident interviews. Resident interviews revealed no concerns noted or expressed at the time of the visit. Residents reported that a variety of activities are offered and provided, and that food substitutions are available upon request. Report Continued on LIC 809-C PAGE 3 ... (PAGE 3) Report Continued from LIC 809-C PAGE 2... 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. On the initial visit 04/06/2026 a 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 which poses a potential health, safety, and personal rights risk to residents in care. LPA advised Resident Service Director (RSD) and Med Techs the importance of proper documentation to ensure medication audit and count is correct. RSD agreed to conduct an internal audit to ensure all records have the correct start date documented on the centrally stored medication and destruction record. During todays visit at 3:32 p.m. LPA conducted a brief medication audit and observed that the facility has began the internal audit of resident medications. Documents: Documents obtained during the visit include: Limited Liability insurance, Staff roster and a Resident roster. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.