Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Director of Wellness Sev Tienda and explained the purpose for todays visit.

The facility is licensed to serve a capacity of two hundred (250) residents ages 60 and above, with a maximum of (25) Non-Ambulatory in the Bradbury Building. There is an approved Hospice Waiver on file for six (4) residents. There is an approved Dementia Care plan is in place. This is a Continuing Care Retirement Community (CCRC) which includes separate buildings throughout the premises ; Independent Living, Assisted Living and Skilled Nursing. The Assisted Living residents reside on the second floor of the Bradbury Oaks building and o ther residents are at the Independent Living care section. The w ander guard system is used in the Bradbury Oaks building (second floor) for residents diagnosed with dementia or wand ering behaviors, this was tested during visit and was in working order.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility has sufficient PPE supplies and there is an Infection Control Plan.

Operational Requirements: The facility has an approved fire clearance and facility maintains the required liability insurance.

Physical Plant & Environment Safety: LPA toured facility, multiple residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facilities residents private bathrooms and measured within the required range of 105-120 degrees. There are multiple shaded patio/garden areas for residents. (continued on 809-C)