Facility Evaluation Report

License Program Analyst (LPA) Shannan Hansen arrived unannounced to complete an Annual inspection of facility. LPA met with Administrator, Denise Downey. There is a total of 23 residents at this full memory care facility, nine living in the completed west side of the facility while 14 remain on the East side. There is one resident currently on Hospice.

LPA reviewed a sample of staff records at 12:10 PM on 9/9/2025 and learned that all facility staff present and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff at the facility have received additional training requirements;although staff (S1 & S2) did not have initial medication or annual training's in records (see LIC809D). As well 3 of 6 staff files reviewed did not have either Health Screening or TB results (see LIC809D). LPA was presented with proof of CPR & 1 st Aid certification for staff that files were reviewed.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..

LPA requesting Licensee to update the following documents by 9/26/2025:

LIC 610 Emergency Disaster Plan (if changes)

Copy of Certificate of Liability Insurance