Facility Evaluation Report

Licensing Program Analysts (LPA) K. Brown and M. Medina arrived unannounced to conduct the Annual Inspection. LPAs met with and explained the reason for the visit with Health Services Director (HSD) Lupe Fierros

During this visit, LPA Brown toured the facility with HSD including Independent Living, Assisted Living and Memory Care. Resident apartments and common areas were clean, in good repair containing required furnishings and lighting. LPA observed required items in bathrooms which were clean with hot water measuring between 113-115 degrees. LPA observed hygiene items, paper products, towels, extra bedding, and linens which were available for use in all areas. The kitchen was clean, containing necessary cooking items and appliances. LPA observed required food supply, including emergency food. There is a medication room located in Memory Care and in Assisted Living. Medications are centrally stored and distributed by Med Techs. Doors and passageways are unobstructed throughout the facility including outdoors.

LPA walked outside to find the grounds well-kept with patios, walkways and seating areas. Delayed Egress was in working order from Memory Care. Fire extinguishers were 1/8/26 by Johnson Controls. The Fire sprinkler system inspection was conducted 6/23/26. During this visit, LPAs conducted resident and staff file reviews including a medication audit. Fire and Emergency Drills are up to date.

LPAs observed the following deficiencies during today’s inspection:

-Medications and Cleaning supplies were accessible in resident apartments

-Employee and Resident files were incomplete and not up to date

-An oven in Memory Care is accessible to residents and needs a protective mechanism to prevent access

-The facility does not have a designated Administrator and has not notified CCLD of the vacancy

SEE LIC809-C FOR CONTINUATION OF THIS REPORT