Non-compliance follow-up·January 26, 2026

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a Case Management - Legal/Non-compliance visit at 10:25 a.m. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on 06/25/2025. As a result of the non-compliance conference, the Licensee is placed on frequent monitoring for a period of one (1) year. The LPA met with Kailey Vanderwall, Executive Director (ED) and Ketmany Nantavong Health Servies Director and explained the reason for the visit. During today’s visit, LPA focused on the physical plant / surrounding grounds. 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 double-story residence that consists of a memory care unit, and an assisted living unit. LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 02/27/2025. LPA observed all the required postings in the Activity Room near the entrance area, and throughout the facility. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Activities observed on both units. Common Areas: These included the beauty salon, library, activity room, theater, fitness center, bistro, and dining areas in assisted living and memory care units. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Fireplaces were properly screened. LPA observed designated storage / utility rooms with emergency food and water. 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. Bedrooms: There are eighty -six (86) total apartments in the facility, fifty-nine (59) assisted living of which ten (10) are open studios, twenty-three (23) are one bedrooms, fifteen (15) are two (2) bedrooms, and eleven (11) studios with a double occupancy in the two (2) bedrooms, one (1) bedrooms, and open studios with a one hundred and seven (107) capacity. There are twenty-seven (27) apartments in memory care of which twenty one (21) are studios and six (6) are one (1) bedrooms with a double occupancy in the open studios, and one (1) bedrooms with a capacity of thirty- three (33) with a total capacity of one hundred and forty (140) in all. They are approved for eight (8) bedridden residents, and have a hospice waiver for fifteen (15). LPA observed ten (10) randomly selected resident bedrooms, (105, 107, 201, 243, 240, 229, 110, 114, 125A, 125B) of which six (6) 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. 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 105.3 - 110.0 degrees Fahrenheit all within the required range. 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. Snacks and beverages are available for residents in the dining area. Knives are stored and inaccessible to residents. Refrigerator and food pantry were checked for proper labels and expiration dates. Documents: Documents obtained during the visit include: Facility / Staff roster and a Resident roster. No citations issued. Exit interview conducted. Copy of report reviewed and provided.