Facility Evaluation Report

Licensing Program Analysts (LPA) Zabel Chochian arrived unannounced to conduct a required annual visit. Upon arrival, LPA met with Executive Director (ED), James Mackay, and Assisted Living Director, Shaulett Dela Cruz. The reason for the visit was stated. Entrance interview conducted. Copy of the residents and staff roster obtained. Current census is 52 of which three (3) residents are receiving hospice services and ten (10) residents are receiving home health services.

Facility's approved Infection Control Plan and Emergency Disaster Plan was reviewed with the ED. Both plans have been reviewed with in the year and no changes were made. The facility has a comprehensive disaster plan. Emergency disaster drills are conducted quarterly as per regulation; monthly fire drills conducted the last one being a fire drill and was conducted in 02/2026 and major disaster drills conducted quarterly; last one being an earthquake drill (great shake out) in 10/2025.

At approximately 12:30 p.m., LPA, ED, Assistant Director Shaulett Dela Cruz and Safety Director John Miller and his team toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations.

COMMON AREAS: The facility is a two story building; units are designated for assisted living residents on the first and second floor, and a separate unit on the first floor is designated for dementia care. There were no obstructions and/or tripping hazards observed. The facility maintains a comfortable temperature. The fire extinguishers were charged and last serviced 1/23/2026. Smoke Detectors and Carbon Monoxide detectors were tested by Service Pro-Fire Protection Inc. on 12/8/2025; all were found functioning properly. Individual smoke and carbon monoxide detectors in resident rooms were tested during today's visit by the Safety team. Seven out seven room smoke and carbon monoxide detectors tested were operational.(Continue to Lic809c)