Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Director of Wellness Sev Tienda and Director of Business Service Mike Carrasco who assisted with the visit. The facility is licensed to serve a capacity of two hundred (200) Non-ambulatory residents ages 60 and above. There is an approved Hospice Waiver on file for six (6) residents and an approved Dementia Care plan. This is a Continuing Care Retirement Community (CCRC) which includes separate buildings throughout the premises. The Assisted Living residents are located in the Memorial Lodge (ML) and Shu Lodge (SL). Memory Care is approved for 12 residents which is located in the Hacienda Building. Facility is approved to lock both exterior doors on the perimeter gates in the memory care unit/hacienda building. T here are currently 34 residents residing in Assisted Living, 10 residents in Memory Care and 132 residents in Independent Living. There is currently one resident on Hospice.

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

Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.

Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and training and facility maintains the required liability insurance.

Physical Plant & Environment Safety: LPA toured facility, a total of 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 facility resident 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)