Facility Evaluation Report

Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct an Annual Required - 1 Year inspection, at approximately 9:45am on 6/4/25, and met with Administrator Megan Leone. LPA toured the facility, assisted living (AL) main building, and the memory care (MC) building, with administration staff, Megan Leone, Administrator/ED, Joel Gonzalez, Business Office Director (BOD), and Michelle Simpson, Health Services Director.

Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has a plan of operation for dementia care. The facility has a hospice waiver approval for ten (10) residents.

Fire clearance is approved for one hundred and seventy-three non-ambulatory, of which 16 may be bedridden. Capacity breakdown as follows: AL main building, and the five (5) bungalows are cleared for one hundred and forty (140) non-ambulatory, of which six (6) may be bedridden, the MC building is cleared for thirty-three (33) non-ambulatory, of which ten (10) may be bedridden; Total license capacity is one hundred and seventy-three (173) . The delayed egress is approved, per fire clearance.

Per review of the emergency disaster drills binder, the facility is completing quarterly drills as required.All exits were clear and unobstructed. Facility fire extinguishers were serviced and tagged as required. All stairwells, four (4) in AL, and one (1) in MC, all had the required emergency evacuation chair, including all had instructions on use posted up.

LPA reviewed ten (10) resident files, including medications, and medication records were reviewed.

LPA reviewed ten (10) staff files. All staff had required criminal record clearance. All staff have required training.

Facility has sufficient supply of perishable and non-perishable food. Freezer and refrigerator was observed to be orderly, and within required temperature (s).