Enso Village, A Kendal Affiliate

Type of visit: Required - 1 Year

At approximately 8:55 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a 1-Year Required inspection. LPA was greeted by Administrator, Anne Nakiyuka at 8:40 AM. Enso Village, a Kendal Affiliate serves older adults in Independent living, Assisted Living and Memory Care. The facility is licensed as a Residential Care Facility for the Elderly-Continuing Care Retirement Community (RCFE-CCRC). The Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for four hundred (400) non-ambulatory residents. The facility has an approved hospice waiver for ten (10) residents. The facility consists of multiple buildings, all of which are inter-connected by paved walkways. LPA was informed that there were 307 Residents in care. At approximately 10:30 AM LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 11:00 AM LPA toured the facility with Administrator Nakiyuka. The facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. All common areas, hallways, and bathrooms observed by the LPA had sufficient lighting. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing/showering as needed. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility offers a wide variety of menu options for the residents at each meal. There is a main dining room and a smaller dinning room available for assisted living residents. There is also a separate kitchen offering strictly vegetarian and vegan options for residents. Snacks are available to residents at all times. The Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. All toxins/cleaners were locked and inaccessible to residents in care. Hot water temperatures for a sample size of fifteen (15) sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. All stairwells had evacuation chairs per regulation. Continued on 809-C... ...Continued from 809 The buildings' smoke and carbon monoxide detectors and sprinkler system were last inspected in 5/2025. All exits were observed to be unobstructed. All fire extinguishers were serviced and tagged in 8/2025. The facility conducts disaster drills quarterly. The last disaster drill was conducted on 8/14/2025. LPA also followed up on an incident report that was submitted to Community Care Licensing (CCL) by the facility. The Incident report stated that a Memory Care resident (R1) was found walking outside of the Memory Care unit. The delayed egress door alarm where the resident exited the memory care unit was not functioning. The facility will be cited for the delayed egress door alarm not functioning. The facility had the door repaired immediately. The facility has begun checking the delayed egress door alarms twice a day and has begun keeping logs of the delayed egress alarm tests. It addition, the facility has added alarms to each door so that facility security and staff are alerted when the alarm is activated. As such, the deficiency has been cleared during today's visit. LPA was unable to complete the Annual Inspection. An Annual Inspection Continuation Visit to be conducted at a later date. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, 811 Confidential Names, Letter of Deficiency Clearance and Appeal Rights discussed and provided to Administrator Nakiyuka. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 10, 2025

Type of visit: Case Management - Other

At approximately 8:40 AM Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management inspection and met with Administrator Anne Nakiyuka. The purpose of today's inspection was to confirm that areas of concern with the facility's new Memory Care unit noted during a 3/4/2025 inspection have been addressed/corrected. The areas of concern are: Memory Care unit entrance door located in Memory Care lobby/waiting room to be repaired and delayed egress operational from both sides as well as faulty wire repaired/replaced. Memory Care kitchen faucet to dispense hot water with temperatures measuring within regulation. Memory Care range/oven to have barrier in place making any hot elements inaccessible to residents in care. Memory Care refrigerator lock removed. Bathrooms in Memory Care kitchen to dispense hot water with faucet functionality such that Memory Care residents can use them without difficulty. Each Memory Care resident unit will need a slip-resistant mat, strips, or flooring in all bathtub and shower floors. All slip-resistant mats, strips, or flooring must be in good repair and maintain slip-resistant properties. The three [3] exit areas: The north-facing Dovetail exit door, Building H stairwell exit door, and Building I stairwell exit doors to have a barrier preventing Memory Care residents from accessing non-secured area of the facility. At approximately 9:15 AM LPA toured the Memory Care unit with Administrator Nakiyuka. Continued on 809-C... ...Continued from 809 During today's inspection LPA toured the Memory Care unit and Memory Care apartments I168, I167, H154 and H157. During the inspection LPA observed the following: Memory Care unit entrance door located in Memory Care lobby/waiting room was observed to be fully functional and operational. Memory Care kitchen faucet hot water temperature was observed at 118 degrees Fahrenheit which is within the Title 22 regulations of 105 to 120 degrees Fahrenheit. Memory Care range/oven was observed to be fitted with a fire proof and heat resistant barrier mat specifically designed to be placed on a hot cook top to protect users from residual cook top heat. Memory Care refrigerator lock was removed. Bathrooms in Memory Care kitchen and in the Memory Care apartments noted above were observed to have faucet hot water temperatures within the Title 22 regulations of 105 to 120 degrees Fahrenheit. Memory Care resident apartments were observed to have slip-resistant flooring on all shower floors. All slip-resistant flooring was observed to have slip-resistant properties. The three [3] exit areas: The north-facing Dovetail exit door, Building H stairwell exit door, and Building I stairwell exit doors were observed to have to have a barrier with delayed egress doors to prevent Memory Care residents from accessing non-secured areas of the facility. All doors were tested and observed to be fully functional. The areas of concern noted in the 3/4/2025 inspection have been addressed and corrected. Community Care Licensing has approved the Memory Care unit for resident occupancy. No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to Administrator Nakiyuka. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 29, 2025

Type of visit: Case Management - Incident

At approximately 9:15 AM, Licensing Program Analysts (LPAs) Robert Frank and Elias Magdaleno arrived unannounced to conduct a Case Management - Incident visit and met with Executive Director (ED) David Smart and Administrator, Anne Nakiyuka. LPAs are conducting a case management to obtain more information on a resident incident that was reported by the Administrator. LPAs reviewed resident (R1's) records. LPAs requested copies of specific resident records. Copies were provided to the LPAs. No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to Administrator Nakiyuka. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 19, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management inspection and met with Annet Nakiyuka, Administrator (Admin). LPA and Admin conducted a tour of Memory Care (MC) units, part of facility's "Phase 3C" expansion. On 2/25/2025, fire clearance was granted for increased capacity of 400 non-ambulatory residents, an increase from 376 residents to now include Memory Care. Memory Care units are located on Level 1 of the Main Building in sections H and I. Facility has a MC lobby waiting area in which the entrance door to the MC unit is located. Currently, the door does not latch and is not working as a delayed egress door. LPA and Admin spoke with Darcy Wallace, Director of Facilities (DOF). He explained that the door is being repaired and will have a magnetic function added to it such that it will latch properly and function as a delayed egress door from both sides. He also indicated that they identified a faulty wire related to the functionality of the door that is also being repaired/replaced. Kitchen for MC unit includes access to refrigerator, sink, and range/oven. LPA noticed locking mechanism on the refrigerator. Admin explained that it will be removed and was only there temporarily. LPA and Admin tried to get a hot water temperature reading from the kitchen sink but could not get any hot water to dispense. Bathroom sinks in the kitchen bathrooms also do not dispense hot water and only dispense water when the motion sensor is activated and a hand (or solid object) is maintained in front of the sensor. LPA and Admin discussed this functionality to potentially be problematic for MC residents to use. Admin will look for an alternative option and report back to LPA. Range/stove top of oven in MC kitchen has a locking feature. A key must be inserted into the lock on the wall to in order for the knobs on the oven to function properly and turn on the heating elements. LPA and Admin discussed adding a barrier of some kind that will prevent MC Continued on 809C... Continued from 809... residents from accessing the hot stove top after it has been in use. Admin will look for an option and report back to LPA. Kitchen has a storage closet and laundry room, LPA and Admin discussed ensuring these doors are locked at all times, including the laundry room. Laundry room does have a storage cabinet with locking function for detergents and toxins. LPA and Admin toured MC resident units I166, I175, H164, and H156. All units have windows that open a maximum of 3-4 inches. Bathrooms all have grab bars, but each unit will need a slip-resistant mat, strips, or flooring in all bathtub and shower floors. All slip-resistant mats, strips, or flooring shall be in good repair and maintain slip-resistant properties. All bedrooms and bathrooms have pull cords. Water temperature in sinks accessible to residents measured at 114.5 degrees F in room I166, and 105.5 degrees F in room H164, which are both within the allowable range of 105 to 120 degrees F. MC unit common area has a device that looks like a fireplace but is actually a Water Vapor Electric Fireplace that runs on tap water. It is not hot to the touch and does not get hot while in operation. MC unit has fire extinguisher cabinets on the walls that are locked with padlocks. LPA asked Admin about the padlocks, Admin advised this is allowed per the fire marshal. Admin explained facility wants to padlock them for safety reasons. Admin showed and forwarded to LPA email from fire marshal allowing the padlocks to be present. Emailed states, per California Fire Code (CFC) 906.8 Cabinets: "Cabinets used to house portable fire extinguishers shall not be locked. Exceptions: in group I-3 occupancies and in mental health group I-2 occupancies, access to portable fire extinguishers shall be permitted ot be locked or to be located in staff locations provided that staff has the keys." Group I-2 occupancy is a classification for buildings that provide medical care to more than five [5] people who are unable to care for themselves. Supervised living facilities are categorized as group I-2. While touring the MC unit, LPA and Admin identified three [3] areas that may present as problematic in regards to elopement: The north-facing Dovetail door (with identification placard labeled Guest Lobby at Boxheart Dr), Building H stairwell exit, and Building I stairwell exit. Each of these exits open up to a Continued on 809C(2)... Continued from 809C... non-secured area of the facility. The Building I stairwell exit opens up to a high-traffic area of the facility where the trash compactor, trash bins, the parking garage, and generators are located. Admin discussed with LPA her ideas of adding a perimeter fence along the paved areas immediately surrounding these exit doors. Admin will discuss options with DOF and report back to LPA. Prior to the admission of Memory Care residents being approved, the facility will address/correct the following areas of concern: Memory Care unit entrance door located in Memory Care lobby/waiting room to be repaired and delayed egress operational from both sides as well as faulty wire repaired/replaced. Memory Care kitchen faucet to dispense hot water with temperatures measuring within regulation Memory Care range/oven to have barrier in place making any hot elements inaccessible to residents in care Memory Care refrigerator lock removed Bathrooms in Memory Care kitchen to dispense hot water with faucet functionality such that Memory Care residents can use them without difficulty Each Memory Care resident unit will need a slip-resistant mat, strips, or flooring in all bathtub and shower floors. All slip-resistant mats, strips, or flooring must be in good repair and maintain slip-resistant properties. The three [3] exit areas: The north-facing Dovetail exit door, Building H stairwell exit door, and Building I stairwell exit doors to have a barrier preventing Memory Care residents from accessing non-secured area of the facility. Admin will contact LPA once all items have been addressed/corrected. Addressed/corrected items to be approved by CCL before any occupancy of Memory Care units. No deficiencies cited. Exit Interview conducted with Administrator.the state’s words, verbatim · CDSS document, Mar 4, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and met with Annet Nakiyuka, Administrator. At approximately 9:45am LPA spoke with Doug Helman, Interim CEO, via telephone to inquire as to the status of the facility's current Administrator of record, Tammy Morrato. CEO explained that Tammy Morrato was only ever intended as an interim Administrator until a permanent replacement was hired. LPA advised that the facility must give CCL at least 30 day notice whenever there is a change in Administrators. LPA advised that the required documents to process and approve the change of Administrator have not been received for Annet Nakiyuka, nor has CCL received notification that a change in Administrator was planned. Interim CEO will send required to documents to CCL as soon as possible. At approximately 11:00am LPA and Admin toured the physical plant. The facility was found to be clean and at a comfortable temperature. Facility has two kitchens; one main kitchen currently utilized. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. All open food items and bin pantry items were labeled with contents and date of opening. Food was found to be of quality and a wide variety of fresh fruits and vegetables were readily available. Kitchen was clean, well organized, and LPA observed kitchen staff adhering to safety and sanitation best practices. Kitchen cleaning supplies and toxins are stored away from any food storage or preparation areas. Water temperature measured at 130 degree F; caution/warning signs were present at each sink. LPA, Admin, and kitchen lead discussed adding verbiage indicating water temperature is over 125 degrees F. Fire extinguishers were last inspected 9/25/2023. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired and last serviced by Johnson Controls Fire Protection on 12/1/2023. At approximately 2:30pm LPA conducted review of six [6] staff records. All required documentation present. Continued on 809C... Continued from 809... In addition to annual inspection of the physical plant, LPA also conducted inspection of Assisted Living units, part of facility's "Phase 3B" expansion. On 8/22/2024, fire clearance was granted for increased capacity of 376 non-ambulatory residents, an increase from 222 residents to now include Assisted Living. The fire clearance for the increased capacity does not include any Memory Care units and is not applicable to Memory Care. Assisted Living units are located on level 2 of Building I in sections H and I. Kitchen for Assisted Living accessible only by key card, which includes access to sink and range/oven. Water temperature in sinks accessible to residents in care measured at 117.5 degrees F in room I272, 114.4 degrees F in room H262, and 112.7 degrees F in room H267, which are all within the allowable range of 105 to 120 degrees F. Per CCL inspection completed 3/6/2024, prior to Assisted Living and Memory Care being approved, Administrator was to provide a written plan indicating how potential areas of risk including, but not limited to, fountains, bioswales, heaters, car garage, and compacter will remain safe for residents in care. As of today, CCL has not received any such plan. Therefore, prior to any Assisted Living residents moving in, Administrator must provide a written plan indicating how potential areas of risk including, but not limited to, fountains, bioswales, heaters, car garage, trash compacter, and pool now in operation will remain safe for residents in care. Written plan to be approved by CCL before any occupancy of Assisted Living units. Annet Nakiyuka Administrator Certificate 6061965740 expired 4/11/2024. LPA verified Administrator renewal certificate application has been received and new Admin certificate number will be 7027319740. All fees are current as of this time. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC308- Designation of Responsibility, Liability Insurance declarations page. Exit interview conducted with Admin. No deficiencies cited.the state’s words, verbatim · CDSS document, Sep 12, 2024

Allegation investigated: Residents are inhabiting area(s) of the facility that do not have a fire clearance

At approximately 9:00AM, Licensing Program Analyst (LPA) Christi Coppo and Licensing Program Manager, (LPM) Victoria Bertozzi arrived at this facility unannounced, to deliver findings regarding a complaint investigation into the above allegations. LPA and LPM met with VP of Operations, Nestor Mendez and Rosemary Jordan, CEO. Residents are inhabiting area(s) of the facility that do not have a fire clearance – Complaint alleges that residents are inhabiting area(s) of the facility that do not have a fire clearance. On 1/31/2024 CCL received notification that a witness observed a resident on the 2nd floor (G wing) in their unit after hours, specifically at 9:09 PM. This observation was documented with a photograph. Per review of email communication from the Healdsburg Fire Dept Fire Marshal to Enso’s CEO Rosemary Jordan, no individuals were to be in the areas lacking fire clearance outside of business hours. Continued on 9099C... Substantiated continued from 9099... During 2/2/2024 visit, CCL staff toured rooms located on the 2nd floor in the G wing which were not fire cleared. CCL observed items such as an opened sleeping bag on top of tri-fold mattress which appeared slept in, medications including over the counter prescriptions, a weekly pill organizer with pills present, toothbrushes, toothpaste, tongue scraper, mouthwash, body wash, shampoo and shower squeegee as well as refrigerator stocked with perishable food and waste baskets full of perishable food waste. CEO, Rosemary Jordan, indicated that items such as toothpaste were used for good daytime oral hygiene and mattresses used for a brief rest during the hours of 8am-5pm. Per letter received by CCL on 2/26/2024 from facility a resident was confirmed in their unit after 9:00pm but facility considers it an isolated incident. Based on observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter number, are being cited on the attached LIC 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and VP of Operations and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 6, 2024 · control 21-AS-20240131130354

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87203 · Plan of correction due date: Mar 13, 2024

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as eveidence by: Based on observation and review of photo, the licensee did not meet this requirement by resident being observed in a non fire cleared room after the hours designated by the Fire Dept. This is a potential risk to health and safety of residents.the state’s words, verbatim · CDSS document, Mar 6, 2024

Plan of correction: Area identified now have a fire clearance. Facility to submit self-certification that remaining areas that have not yet received a fire clearance will be entered only as permitted by the fire department. Occupancy requires approval by CCL. Plan of Correction due no later than 3/11/2024.

Type of visit: Case Management - Other

Licensing Program Analyst Christi Coppo and Licensing Program Manager, Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Rosemary Jordan and Nestor Mendez, VP of Operations. Floors 3-4 building I,H,G and Floor 2 of building G have been approved by the local fire department to allow for 222 non-ambulatory residents. This approval does not allow for occupancy for Assisted Living or Memory Care in any capacity. The non-approved restricted areas generally identified as such are first floor buildings I, H, G and 2nd floor buildings I, H, and the 2nd floor commercial common kitchen. On-site parking must be adequate for the actual number of occupants’ vehicles. Fire lanes are not to be blocked at any point by residents, staff or construction vehicles. This approval is an extension to the previous STD850 and includes the following units: Floor 2 Northeast wing (G wing): U246, U247, U248, U249, U250, U251, U252, U253 Floor 3 Northeast wing (G wing): U346, U347, U348, U349, U351, U352, U353 Floor 3 North wing (H wing): U355, U356, U357, U358, U359, U360, U361, U362, U363, U364, U365 Floor 3 Northwest wing (I wing): U357, U365, U366, U367, U368, U369, U370, U371, U372, U373, U374, RES ST 375, Guest 378, Floor 4 North wing (H wing): U455, U456, U457, U458, U459, U460, U461, U462, U463, U464, U465 Floor 4 Northwest wing (I wing): U457, U465, U466, U467, U468, U469, U470, U471, U472, U473, U474, Guest 478 Continued on LIC809C... Continued from LIC809... LPA initiated a tour of the areas identified in Phase 3A around 9:15am and observed the following: Areas identified as needing final TCO and fire clearance have been completed. LPA confirmed through observation that the water temperature in sinks accessible to residents in care measured at 115.8, 115.6, 119.4 and 120.8 degrees F which is just outside the the allowable range of 105 to 120 degrees F. LPA discussed with VP of Operations turning the water heater down just slightly to mitigate occurrence of temperature breaking the threshold of 105 to 120 degrees F, as required per regulation. LPA and Administrator discussed the importance of maintaining safety while area is still under partial construction. Prior to Assisted Living and Memory Care being approved, Administrator must provide a written plan indicating how potential areas of risk including but not limited to fountains, bioswales, heaters, car garage and compacter will remain safe for residents in care. LPA will update capacity to allow for 222 independent residents on the aforementioned floors and unit numbers. No deficiencies cited during this visit.the state’s words, verbatim · CDSS document, Mar 6, 2024

Allegation investigated: Licensee does not ensure facility grounds are free from hazards Facility is not providing a comfortable environment

At approximately 9:00AM, Licensing Program Analyst (LPA) Christi Coppo and Licensing Program Manager, (LPM) Victoria Bertozzi arrived at this facility unannounced, to deliver findings regarding a complaint investigation into the above allegations. LPA and LPM met with VP of Operations, Nestor Mendez and Rosemary Jordan, CEO. Licensee does not ensure facility grounds are free from hazards - Complaint alleges that facility has a drainage problem on the facility grounds which is causing multiple large pools of water to collect and cover resident walkways outside. During the 12/29/2023 visit, CCL staff observed accessible "bioswales" which are defined areas of landscaping that drop down to create a pool. Not all were fenced to mitigate risk on 12/29/2023. LPA and LPM confirmed through observation on 12/29/2023 and 2/2/2024 that there are other areas of concern that are hazardous including but not limited to construction debris, accessibility to the car barn and compactor and an area of the facility that collects water. Continued on LIC9099C Substantiated Continued from 9099... Facility is not providing a comfortable environment - Complaint alleges that facility elevators in all ten buildings are not operational. Additionally, residents are having issues with HVAC fans in their private rooms that run all the time and cannot be manually turned off, which allows cold air to flow in from outside. Per complaint, the HVAC system makes a loud whistle/whirring noise, causing some residents to not be able to sleep. Also, the thermostats in most rooms are not working or are too complex for residents to operate, resulting in residents not having heat in their rooms. Some were provided with temporary space heaters. LPA and LPM confirmed through the staff interviews on 12/29/2023 that the HVAC in Meadows building does have sound issues and that the problem was identified as being due to insufficient springs on the roof. It was communicated to CCL staff on 12/29/2023 that the HVAC springs are on order and the facility is waiting for the shipment to arrive. Per staff interview conducted today, the springs have not arrived and there is not estimated time of arrival for the springs. The sound issues have been present since the residents moved in. The temperature in residents units is a known issue. Per staff interview some units are still having issues with temperature, however the facility have provided space heaters for some and installed a more traditional heating thermostat to work in conjunction with existing thermostat, in order to mitigate thermostat error. Based on LPA and LPM observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter number, are being cited on the attached LIC 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Feb 2, 2024 · control 21-AS-20231221142319

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 9, 2024

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on CCL observation facility has accessible "bioswales" pools, some of which were not fenced. Other observed hazards include: construction debris and accessibility to: car barn, compactor and an area of the facility that collects water. This poses a potential risk to health and safety.the state’s words, verbatim · CDSS document, Feb 2, 2024

Plan of correction: Facility to provide written plan of how noted areas will be addressed to mitigate risk to all residents in care. Facility to submit plan to specify how facility will mitigate identified risks. Faclity to submit plan by plan of correction due date of 2/9/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 9, 2024

87468.1 Personal Rights of Residents in All Facilities (a)Residents in all RCFEs shall have all of the following personal rights: (2)To be accorded safe, healthful & comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on CCL interview with staff and observations, there are issues with heating and noise which poses a potential risk topersonal rights.the state’s words, verbatim · CDSS document, Feb 2, 2024

Plan of correction: Facility provide update regarding HVAC system and how they will mitigate noise created. Facility to provide plan of how they will ensure residents' apartments are able to maintain a comfortable temperture.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Rosemary Jordan. Facility has requested a change of capacity to add additional apartments as part of their second phase. All apartments are designated for residents who are independent. The facility does not plan to add apartments for residents in assisted living and memory care until their third phase. LPA initiated a tour of the remaining building identified in Phase 2 around 3:30pm and observed the following: "The Meadows" is a building separate from the main building that has 20 independent resident apartments that has not yet been approved by the local fire district. Based on tour, "The Meadows" meets the requirements of licensing but will need final approval by the fire district before residents may move in. LPA observed a temporary railing at the exterior sidewalk. Per conversation with facility representatives, the railing will be installed by the end of this week. Once railings are installed, Administrator agrees to submit a picture of railing to LPA. LPA and Administrator discussed maintaining safety while area is still under partial construction. Additionally, Administrator will provide a written plan indicating how potential areas of risk including but not limited to fountains, bioswales, heaters and compacter will remain safe for residents in care. Once LPA has received pictures of the permanently installed railings and an approved fire inspection report, facility will be approved for an increase in capacity to include "The Meadows".the state’s words, verbatim · CDSS document, Nov 30, 2023

Type of visit: Case Management - Other

Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Rosemary Jordan. Facility has requested a change of capacity to add additional apartments as part of their second phase. All apartments are designated for residents who are independent. The facility does not plan to add apartments for residents in assisted living and memory care until their third phase. LPA initiated a tour of the areas identified in Phase 2 around 2:00pm and observed the following: Areas identified during the 11/17/2023 visit as needing final construction have been completed. The facility has a Zendo that is part of Phase 2 but is not yet completed .Completion date is pending but building is locked to ensure resident safety until completed. LPA confirmed through observation that the exterior door from the Balance Room has been secured so individuals may not access the patio while it is still under construction. Floors 2-4 have been approved by the local fire department to allow for 98 residents. The apartments are approved for non-ambulatory residents, however, the local fire department has specified that at this time, only ten non-ambulatory residents may reside on floors 2-4. A separate building identified as "The Meadows" has not yet been approved by the local fire district despite being part of Phase 2. The Meadows has a capacity of twenty independent residents and without that approval, the fire department has updated the fire safety inspection report to allow for 98 residents instead of the 118 requested by facility. LPA and Administrator discussed the importance of maintaining safety while area is still under partial construction. LPA will update capacity to allow for 98 independent residents in the main building, floors 1-4.the state’s words, verbatim · CDSS document, Nov 20, 2023

Type of visit: Case Management - Other

Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Rosemary Jordon. Facility has requested a change of capacity to add additional apartments as part of their second phase. All apartments are designated for residents who are independent. The facility does not plan to add apartments for residents in assisted living and memory care until their third phase. LPA initiated a tour of the areas identified in Phase 2 around 1:20pm and observed the following: Facility is completing final construction including but not limited to painting, wall touch ups, electrical outlet covers and some landscaping. Facility is also completing a sidewalk outside of a separate building that would house twenty independent residents. These final items are anticipated to be completed no later than 11/20/2023. The facility has a Zendo that is part of Phase 2 but not yet completed. Area is locked to ensure resident safety until completed and anticipated completion date is 11/22/2023. The Balance Room is completed and facility would like to utilize the space prior to the patio area being completed. Individuals do not need to use the patio to gain access to the room so facility will create a physical barrier to make the patio inaccessible while still allowing for residents to use the space. LPA will return once construction areas are complete. No deficiencies cited.the state’s words, verbatim · CDSS document, Nov 17, 2023

Type of visit: Prelicensing

Licensing Program Analyst Bertozzi arrived announced to conduct a Prelicensing inspection and met with Administrator, Rosemary Jordan and Welcome Guide, Kelly Hall. LPA initiated a tour of the facility around 9:15 AM and made the following observations: Facility has four floors but only the first floor is being toured at this time due to facility opening in phases. LPA will return for each phase. Assisted Living and Memory Care areas are planned to be completed during the third phase. Currently, only independent residents have defined move-in dates. Facility has a large commercial kitchen with multiple food storage areas, a smaller bistro style kitchen, private dining room, offices for staff, common spaces, a balance room, and outdoor activity spaces. Required posting were observed. Administrator has reached out to the Local Long Term Care Ombudsman Office to obtain an Ombudsman Poster. A fire clearance has been approved for 82 residents, 78 ambulatory and 4 non-ambulatory. Facility was a comfortable temperature and passageways were free from obstructions. Water temperature in a sample of residences measured at 118, 119 and 121.0 degrees F which are not all within allowable range of 105 to 120 degrees F. Showers in resident bathrooms are textured for safety and grab bars are available. Cleaning supplies are stored in locked storage rooms and once received, locked housekeeping carts will be used. Refrigerators and freezers read at required temperature. Facility has contracted with a company to deliver food multiple times per week and will increase food delivery as facility population increases. Facility has evacuation chairs at each stairwell. Each residence has a call button to alert staff if assistance is needed. Continued on LIC 809C Continued from LIC809 Fire extinguisher was last inspected September, 2023. Facility has a combination Smoke and Carbon Monoxide system that is maintained by a vendor and inspected by the local fire department. Component III will be conducted when the Prelicensing of facility's third phase is completed. Facility has reduced the temperature on the water system and will continue to test water to ensure it is within regulation. LPA has requested that the exit from the Balance Room remains off limits until the patio is complete and exiting is safe. Facility is currently working on landscaping throughout the property that is planned to be completed prior to residents moving in. LPA and Administrator discussed areas of potential risk including but not limited to construction areas, a cardboard compactor and a car barn. Construction areas have been made inaccessible by having temporary walls erected and placing individuals to redirect residents away from potentially dangerous areas. LPA observed that construction materials and tools were inaccessible. LPA will notify the Centralized Application Unit to move forward with the application process.the state’s words, verbatim · CDSS document, Nov 3, 2023

Type of visit: Office

Facility Type: RCFE - CCRC Application Type: Initial Capacity: 82 Census (if any clients in care): 0 COMP II Participants: Rosemary Jordan Interview Method: Telephone interview On October 30, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Oct 30, 2023