Facility Evaluation Report

Licensing Program Analyst (LPA) Daniel Konishi conducted the required unannounced annual inspection. LPA met with Director of Wellness, Eusebio Tienda and explained the purpose for the 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 four (4) residents. The facility also has an approved Dementia Care plan as part of their operation. There are currently 24 residents in Assisted Living and 184 residents in Independent Living.

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

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an Infection Control Plan in place which was last updated on 08/05/2025. Emergency and disaster plan was completed and up to date.

Operational Requirements: The facility has an approved fire clearance and facility maintains the required liability insurance in place. There is an approved Dementia Care plan in place. Last fire drill was last conducted on 09/22/2025.

Physical Plant & Environment Safety: 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 other residents are at the Independent Living care section. The wander guard system is used in the Bradbury Oaks building (second floor) for residents diagnosed with dementia or wandering behaviors, this was tested during visit and was in order.