Routine inspection·June 19, 2025

Licensing Program Analysts (LPAs) Valeria Conway and Martha Arroyo arrived at the facility at 9:15 A.M., for an unannounced required annual inspection. LPAs met with Executive Director, Amber Winterstein and discussed the reason for the visit. Entrance interview conducted. Beginning at 10:30 A.M., the LPAs along with the 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 facility is a two-story and a ground floor building. The following was observed: According to the maintenance director batteries in the smoke detectors are changed once a year. 5-Year fire sprinkler inspection was conducted by Johnson Controls Fire Protection on 02/25/2022, all deficiencies noted on report were repaired and/or corrected by 04/22/2022. No safety concerns were noted at that time. Several fire extinguishers throughout the building were observed to be fully charged and last serviced on 08/30/2024. At 11:21 A.M., carbon monoxide alarm was tested and properly functioned at the time of the visit. Continued on LIC 809-C Continued from LIC 809 KITCHEN : The main kitchen and dining room are located on the 2nd floor. Food is prepared in the main kitchen and delivered to the dining area and the Life Guidance (Memory Care) dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. LPAs observed a minimum of two (2) days perishable and seven (7) days non-perishable foods. LPAs inspected refrigerator and pantry for expiration dates. Kitchen appliances were in operable condition. LPAs observed a sufficient supply of emergency food and water. All knives and cleaning supplies were observed to be properly stored at the time of the visit. RESIDENT ROOMS/RESTROOMS: A random selection of 6 (six) resident rooms in the assisted living side and five (5) random resident rooms in the Life Guidance (Memory Care) were observed. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings and were equipped with a refrigerator, sink, and microwave and contain private restrooms. The bathrooms were observed to be safe and sanitary with grab bars and slip-resistant surfaces and were sufficiently stocked with supplies and paper towels. Starting at 10:34 A.M., the hot water temperature was measured in all rooms inspected. Hot water in four (4) out the eleven (11) rooms checked were above the required range. Maintenance director adjusted the water heater temperature during the visit. Technical violation (TV) issued. During today’s visit, LPAs observed the facility’s response system procedures in the Life Guidance unit. It was noted that staff utilize pagers to respond to residents when assistance is requested via push alert button located in their rooms. While testing the auditory signal system, it was observed that two (2) staff members assigned to the floor did not have their pagers with them and were not aware that the call system was activated for testing. When questioned, the staff stated that the pagers were not functioning due to low battery issues. Maintenance director was informed and replaced malfunctioning pagers with new ones. During today’s visit the new pagers were tested and functioning. Continued on LIC 809-C Continued from LIC 809-C OUTDOOR SPACES: The LPAs and ED toured the outside areas of the facility. The Assisted Living and Life Guidance contained 2 (two) courtyards for resident use. During today’s visit the LPAs observed three (3) operational water fountains on the promises. Two (2) fountains are located in the assisted living area and the other is situated within the Life Guidance unit. The LPAs observed appropriate outdoor furniture, with a covered shaded area for resident use. RECORD REVIEW: Starting at 12:29 P.M ten resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All records were in order. Ten personnel files were reviewed for, but not limited to: personnel records, health assessments with TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files were complete. MEDICATIONS: Medications for the Assisted Living Unit and the Life Guidance unit are centrally stored and locked in their medication room. Medication review began at 2:05 P.M. LPAs observed medications for five (5) residents. All medications observed were stored in compliance with regulation, however, during medication audit it was revealed that two (2) out of five (5) centrally stored medication start date did not match what was recorded on the centrally store medication and destruction record. Technical advisory (TA) issued. INTERVIEWS: Throughout today's visit, LPAs interviewed 3 (three) residents and 4 (four) staff members. Continued on LIC 809-C Continued from LIC 809-C INFECTION CONTROL/EMERGENCY DISASTER: LPAs also reviewed the facility's Emergency Disaster Plan, which was observed to be complete and updated annually as required. Emergency Disaster drills are conducted monthly, with the last drill documented on 05/21/2025. Daily vehicle inspection list, current registration, and insurance was reviewed for facility vehicle. During today’s visit LPAs obtained a copy of the facility’s LIC 500, resident roster and current liability insurance. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.