Facility Evaluation Report

On 09/03/2025, Licensing Program Analysts (LPAs) Arielle Pascua and Triel Ellen Lindstrom arrived unannounced to this facility to conduct a case management visit. LPAs met with Facility Designated Administrator (FDA), Lacy Vincent and explained the purpose of the visit. The purpose of this visit was in response to LPA observations made during a subsequent complaint and case management visit dated September 3, 2025.

During the course of this visit, LPA toured the Memory Care building and the Assisted Living building.

LPA confirmed with facility staff and a resident roster that there are currently 57 residents in Assisted Living and 26 in Memory Care. There are current 2 residents from Memory Care out of the facility at this time. During the visit, LPA observed one caregiver and one medication technician on duty, with one caregiver on a lunch break. Four residents were observed in the dining area, and five were in the living area watching TV. All other residents were in their respective bedrooms.

During a walk-through of the Memory Care unit, LPA observed one resident (R1) in a bedroom with a mesh bed rail with the words "HOMEAL" installed along the full length of the bed. A review of R1’s facility records revealed no physician’s order for the use of a full bed rail, nor is R1 currently on hospice. Staff interviews indicated that the bed rail was installed at the request of a family member concerned about potential falls. LPA Pascua informed staff that a physician's order is required for the use of a bed rail that reaches the full length of the bed. LPA also toured the Assisted Living section, including two resident floors. During this tour, LPA observed three caregivers and one medication technician providing care and supervision to residents.

As a result, the following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was attempted with FDA Vincent and a copy of this report was provided to the facility. A copy of this report will be sent to the Licensee and facility email addresses confirming delivery and read receipt.