The LPA's 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 12/27/2025. 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. In the Memory Care until morning exercise, and daily chronicles were observed.

Interviews: Starting at 11:27 a.m and throughout the visit LPA's conducted eight (8) interviews, four (4) residents, one (1) visitor and three (3) staff interviews. Staff interviews indicated that staff are knowledgeable in resident rights, the various forms of abuse, and appropriate reporting procedures. Resident interviews revealed that no concerns were noted or expressed at the time of the visit. Visitor interview revealed that no concerns were noted or expressed at the time of the visit.

Report Continued on LIC 809-C PAGE 2...

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

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.

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 and twenty-seven (27) in memory care. LPA observed nine (9) randomly selected resident bedrooms, of which six (6) in assisted living and three (3) 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.

Records: were reviewed beginning at 12:46 p.m. Resident Records: Nine (9) 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, wander guard consent forms and current needs and services plan. All records were in order. Personnel Records Five (5) 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.

Facility Records: LPA reviewed the quarterly inspections, testing and maintenance reports for the wet pipe and fire sprinkler system conducted on 01/05/2026, 04/21/2026, and 07/09/2026 indicating a pass in all areas. The five year inspection was conducted in 2022 indicating a pass with the next one scheduled in 2027. All records in order.

Infection Control / Emergency disaster planning: During today’s visit the LPA's 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 last emergency disaster drill took place on 09/19/2026 and conducted monthly 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.

Medication Audit: There are two (2) medication rooms located on each side of the facility. Med Techs distribute medication at the appropriate times to residents in care. At approx. 4:00 p.m. Medication audit for three (3) residents was conducted. 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 and documented on the centrally stored medication and destruction records. No errors observed during review.

No citations issued at this time. Exit interview conducted. Copy of report reviewed and provided.