Everest at Oceanside

Allegation investigated: Facility did not follow procedures to protect food items.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate a complaint investigation on the above allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Brandon Cho and Matia Grochowiak Assistant Executive Director. On September 2, 2026, Community Care Licensing (CCL) receas a complaint alleging facility is not following procedures to protect food items. During investigation, LPA Strong conducted interviews and made observations. According to allegation, facility staff were collecting resident specimens and storing it in refrigerators meant for medication/resident snacks. Photographic evidence collected shows a filled urine sample in a medical cup within a plastic bag stored in a refrigerator with fruit cups, protein shakes and pudding. Interview with multiple staff revealed that at times, resident samples may be stored in these refrigerators. Interviews also revealed that there is no specific refrigeration system meant for storage of human specimen. Substantiated Based on interviews, and observations, a preponderance of evidence exists to support the allegation. Deficiencies are being cited by the California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Brandon Cho and Matia Grochowiak Assistant Executive Director. to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.the state’s words, verbatim · CDSS document, Sep 11, 2026 · control 08-AS-20260902123632

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(9) · Plan of correction due date: Sep 18, 2026

87555 General Food Service Requirements b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability ... of food shall be observed in food storage... This requirement was not met, as evidenced by: Based on interviews and records the licensee did not have procedures in place to protect the safety of resident food which posed a potential Safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: Licensee agrees to establish a system for human specimen storage that does not affect food storage by POC date and provide proof to LPA via email.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Assistant Executive Director Matia Grochowiak . Community Care Licensing received an Incident Report on 6/19/26 in which it was reported that on 6/18/26, a Resident (identified as R1) was being assisted by a staff member with a transfer from their bed to their wheelchair when R1 experienced a sudden loss of leg strength and the staff member assisted the resident to the floor. A second staff member arrived and both assisted the resident from the floor to their wheelchair and the resident reported a dull pain to the right knee. About 30 minutes later staff conducted a follow up check with R1 and no pain was reported and R1 was observed to be participating in activities. Three hours later, the resident reported severe pain to their right knee and emergency services were contacted and R1 was taken to the hospital where a right femur fracture was discovered. During today's visit, LPA conducted file review and consulted with Assistant Executive Director Grochowiak and Business Office Manager Recce about R1's care/supervision needs and the facility's plan moving forward. R1 was not in the community and is receiving services at a nearby SNF (Skilled Nursing Facility). Per review of R1's file, it was noted in both R1's assessment (dated for April 2026) and service plan (dated for May 2026) that R1 required a two (2) assist for all transfers. R1 is additionally labeled as a fall risk in their file. Per review of the incident report and staff charting notes, only one (1) staff member was present assisting R1 with a transfer at the time of incident. [Continued on LIC 809-C] [Continued from LIC 809] A type A deficiency was cited per Title 22 regulations and is noted on the attached LIC 809D. The citation is issued for facility neglect in following R1's care plan and assessment outlining a need for two (2) person transfers. As this is a violation that resulted in an injury to an individual in care, a Zero Tolerance Violation Civil Penalty is being assessed in the total amount of $500.00 and details are noted on the attached LIC 421IM. Additional Civil Penalties are under review by the Community Care Licensing (CCL) Department and may be assessed at a later date. One deficiency was cited during today's visit. An exit interview was conducted with Business Office Manager Sydney-Ann Recce to whom a copy of this report, the LIC 421IM form, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jun 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jul 9, 2026

87468.2: In addition to the rights listed in Section 87468.1 [...] residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8)To be free from neglect [...] This requirement is not met as evidenced by: Based on file review and interviews, the Licensee did not ensure R1 was receiving transfer assistance as indicated in ther care plan, resulting in serious bodily injury to R1, posing an immediate health and safety risk to 1 out of 113 residents in care.the state’s words, verbatim · CDSS document, Jun 26, 2026

Plan of correction: R1 was transfered to a SNF (Skilled Nursing Facility) to meet current care needs. Licensee will conduct an in-service training with staff on care plans and transfer assisrtance. Licensee will submit this to LPA by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Receptionist Betty Oyanguren and Business Office Manager Sydney-Ann Recce. Community Care Licensing received an Incident Report on 6/4/26 in which it was reported that on 6/2/26, a Resident (identified as R1) had made multiple sexual advances on a housekeeper who was attending to R1's unit. Per the report, the facility held a meeting with the resident to address the behavior, along with notifying R1's primary care physician for request of a reassessment in order to see if the Assisted Living unit remains appropriate for R1's level of care. Additionally, housekeeping protocols have been temporarily modified for R1's unit in order to aid in staff safety. During today's visit, LPA consulted with Business Office Manager Recce about R1's care/supervision needs and the facility's plan moving forward. At this time, LPA observed no health and/or safety concerns and no deficiencies were cited during today's visit. An exit interview was conducted with Business Office Manager Recce to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jun 4, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced Case Management visit to follow up on a resident death reported to Community Care Licensing. LPA was welcomed by, identified herself to, and discussed the purpose of the visit to Sydney Recce, Business Office Director. Community Care Licensing received a Death Report on 4/22/26 in which it was reported that Resident #1 (R1) had passed away on 4/19/26 at the facility, following a hospitalization from a fall at the facility on 4/15/26. Per the report, R1 had an unwitnessed fall and was found by care staff and promptly called for emergency services. Per the report, R1 sustained a laceration to bridge of nose and forehead which required stitches in addition to needing a blood transfusion. Upon being discharged back to the facility, R1 was admitted to hospice services. [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] During today's visit, LPA conducted a file review. The facility is currently awaiting the death certificate and will forward to the Department once received. Per LPA file review and interviews, the facility responded appropriately by arranging for prompt medical attention for R1 upon notification of incident. At this time, LPA observed no immediate health or safety concerns and no deficiencies were cited during today's visit. Additional visits and follow-up may be necessary for complete review of this incident based on additional information from the Death Certificate once obtained. An exit interview was conducted with Sydney Recce, Business Office Director to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Apr 23, 2026

Allegation investigated: Facility was not kept in good repair

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow-up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Community Relations Director (CDR) Yadi Moreno. During today’s visit, LPA observed residents in care and interviewed staff. The Department’s investigation consisted of interviews with staff, records review, and a tour of the facility. It was alleged that the facility was not kept in good repair, specific to a water leak in the facility’s memory care building. Interviews and records review revealed that on 2/7/2026, a pipe burst in one of the facility’s memory care buildings at approximately 3:00am during the night shift. Interviews revealed that the water from the burst pipe leaked into the hallway of the memory care and into several resident rooms. Continued on LIC9099-C page... Unsubstantiated Evidence collected during interviews with facility management revealed that the Maintenance Director and Executive Director responded to the incident and were present at the facility within one hour of the plumbing leak occurring. Staff turned off the water and used water extractors, vacuums designed to handle water, and industrial fans to remove the water from the carpet and flooring. Additionally, interviews confirmed that a majority of the water had been removed from the memory care within a few hours of the leak and fans were used to continue the drying process for the carpet. Interviews with maintenance staff revealed that the water was turned back on for the memory care building within a few hours and industrial strength equipment was brought to the facility within a few days to dry to the carpet and remove any smells caused by the water leak. Interviews with memory care staff revealed that a couple of resident rooms were affected by the water leak, which resulted in residents being relocated to the common areas of the memory care while staff addressed the water leak. Staff stated that residents were encouraged to stay in common areas during the day to encourage socialization and participate in activities, which was supported by LPA observations during an on-site visit on 2/13/2026, and residents were able to return to normal use of their rooms by the end of the day on 2/7/2026. During an on-site visit on 2/13/2026, LPA Borunda conducted a tour of the memory care and did not detect any mild or strong odors of wet carpet, mildew, or any other offensive smells in the common areas, hallways, or the majority of resident rooms. One resident room did have a mild odor of wet carpet, however, interviews with the Executive Director during the tour revealed that the resident did not wish to keep their window or door open to allow for proper air flow or the use of fans, which was supported by observation. The carpet in the hallway, directly outside of where the water leak occurred, felt dry to the touch with no noticeable dampness. A couple of resident rooms had plank flooring which was slightly tacky when stepped on but was not determined to be a hazard. The Department has investigated the above-mentioned allegation and based on interviews and observation, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with CDR Yadi Moreno, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 08-AS-20260211083346

Allegation investigated: Licensee did not ensure resident records were kept in secure storage

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow-up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Community Relations Director (CDR) Yadi Moreno. During today’s visit, LPA observed residents in care and briefly toured the facility. The Department’s investigation consisted of interviews with staff, records review, and a tour of the facility. It was alleged that the Licensee did not ensure resident records were kept in secure storage. Interviews with outside sources alleged that resident records were left unattended in an area of the facility. Interviews with staff revealed that resident administrative records were stored in locked cabinets kept in the Business Office Manager’s (BOM’s) office and resident care records were kept in the locked medication room. Continued on LIC9099-C page... Unsubstantiated Generally, resident records were only removed for Department review, to make copies of documents for reporting purposes, or to update resident care charting. Staff stated that when resident records needed to be copied, they would be taken to the facility’s copy room. Staff denied any knowledge that resident records were ever left unattended in the facility’s copy room, however evidence collected during the investigation contradicted these claims. Interviews stated that the copy room is only accessible to facility staff, and LPA observations during on-site visits on 2/20/2026 and 3/24/2026 determined that the copy room could only be accessed through the CDR's office located behind the receptionist desk or via a locked door in a common hallway. Interviews with staff confirmed that the hallway door was locked and only accessible via a key and that all staff had a key to the copy room. The Department’s investigation did not reveal any evidence that resident records were left in areas commonly or easily accessible to residents, visitors, or any other individuals without the presence of facility staff. The Department has investigated the above-mentioned allegation and based on interviews and observation, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with CDR Yadi Moreno, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 08-AS-20260213101823

Allegation investigated: Licensee did not maintain the facility in good repair

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit with Activities Director Karie Winchester. Executive Director Jill McDonald arrived during the visit. During today's visit, LPA observed residents in care and interviewed staff. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the Licensee did not maintain the facility in good repair, specific to mold. Interviews with staff and residents revealed that Resident 1 (R1) alleged that mold was present in their apartment due to a water leak. Interviews with R1 and staff revealed that R1 denied that any water present in R1’s bathroom was due to regular bathroom use. Continued on LIC9099-C page... Unsubstantiated Interviews revealed that R1 notified facility management of their concerns about the mold sometime in late July 2025 and management offered to relocate R1 to another apartment in the facility at no cost to R1. While interviews provided conflicting information for R1 not relocating to the other apartment, interviews and LPA observation during on-site visit on 8/12/2025 revealed that R1 was not relocated to an alternative apartment until 8/12/2025. Interviews with staff and R1 revealed that facility staff tested R1’s carpet using mold test kits purchased at a local retailer and those tests did not show any mold present in R1’s carpet. However, R1 insisted on having a professional company test R1’s apartment for mold, which was scheduled for 8/12/2025. Interviews with staff revealed that following the mold testing, the facility planned on removing R1’s carpet, sanitizing the foundation, and installing non-absorbent plank flooring. Facility management stated that R1 would be relocated to a different apartment on 8/12/2025 to allow for the construction. During the on-site visit on 8/12/2025, LPA Borunda was able to tour R1’s apartment and observe the mold testing conducted in R1’s apartment by the professional mold company. LPA did not observe any mild or strong odors to be present in R1’s kitchen, living room, bedroom, closet, or bathroom. Additionally, LPA did not observe any damp or wet flooring in R1’s apartment. LPA did observe multiple carpet discolorations in R1’s apartment, but, those discolorations did not have any odors, specific coloring, or a clear cause. Review of the inspection report from the mold company revealed that the testing revealed no evidence of mold contamination or water related damage in R1’s bedroom, bathroom, or closet. Additionally, the testing did not reveal any evidence of a leaking pipe or water in the foundation. The report did note that spore count inside R1’s apartment was higher than the outside spore count, which was uncommon, however, the report stated that there are no current state or federal regulations governing mold and indoor air quality. The report also stated that the higher levels could be due to a hidden source, older carpet, dust buildup, or the presence of a small pet. Interviews with staff revealed that the carpet was replaced and the foundation was cleaned and disinfected prior to R1 returning to their room sometime by end of September 2025. The Department has investigated the above-mentioned allegation and based on observation, interviews, and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Executive Director Jill McDonald, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Dec 15, 2025 · control 08-AS-20250805120350

Allegation investigated: Staff handled resident(s) in a rough manner

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Activities Director Karie Winchester. Executive Director Jill McDonald arrived during the visit. During today’s visit, LPA observed residents in care and interviewed residents and staff. The Department's investigation consisted of interviews with residents and staff, review of records, and a tour of the facility. It was alleged that staff handled resident(s) in a rough manner. Review of staff personnel records and interviews with staff revealed that in July 2025, Staff 1 (S1) attempted to redirect Resident 1 (R1) during an behavioral episode and was observed to physically force R1 into a seated position. Continued on LIC9099-C page... Substantiated Interviews with staff and review of staff personnel records revealed that S1 was temporarily placed on disciplinary leave while the facility conducted an internal investigation, and S1 ultimately received a written warning and retraining on abuse and providing incontinence care to residents. Interviews with staff and residents did not disclose any other incidents of rough handling by staff. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. An exit interview was conducted with Executive Director Jill McDonald, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22). Residents stated that staff were pleasant, considerate, and helpful and did not disclose any concerns or complaints regarding staff interactions. Interviews with staff did not reveal any complaints of staff behaviors or any staff that received disciplinary action for yelling or cursing towards residents. The Department has investigated the above-mentioned allegation and based on interviews, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Executive Director Jill McDonald, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Dec 15, 2025 · control 08-AS-20251105121404

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Dec 15, 2025

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above in that R1 was physically forced to sit down, which poses a potential personal rights risk to 115 of 115 residents.the state’s words, verbatim · CDSS document, Dec 15, 2025

Plan of correction: Executive Director stated that S1 received a written warning and retraining on personal rights and abuse. Executive Director provided LPA with a copy of S1's updated training transcript and written warning during the visit. DEFICIENCY CLEARED.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Activities Director Karie Winchester. Executive Director Jill McDonald arrived during the visit. During today's visit, LPA toured the facility, reviewed facility records, and observed residents in care. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed.LPA was away from the facility for approximately one hour between 12:15pm and 1:15pm. No deficiencies were cited on today's date. An exit interview was conducted with Executive Director Jill McDonald, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Nov 17, 2025

Type of visit: Case Management - Licensee Initiated

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Chief Information Officer (CIO) Jane Owens. During today’s visit, LPA provided CIO Owens with guidance regarding the appeal rights, process, and timelines, and guidance regarding civil penalties payment. No deficiencies were cited on today’s date. An exit interview was conducted with CIO Jane Owens, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit regarding a self-reported incident. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Jill McDonald. On 10/17/2025, the Department received a self-reported incident report from the licensee that described an incident that occurred between Resident 1 and Staff 1. [Executive Director was provided with LIC811 Confidential Names List to identify individuals] During today’s visit, LPA conducted a health and safety check, observed residents in care, and reviewed facility records. No deficiencies were cited on today’s date. An exit interview was conducted with Executive Director Jill McDonald, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Oct 20, 2025

Allegation investigated: Staff did not mitigate the rodent infestation at the facility

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to open an investigation and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Jill McDonald. During today’s visit, LPA toured the inside and outside of the facility, including the kitchen, laundry, and boiler rooms, interviewed staff, and reviewed facility records. The Department’s investigation consisted of interviews with staff and outside sources, review of facility records, and a tour of the facility. It was alleged that the facility did not mitigate the rodent infestation at the facility. Interviews with staff revealed that rodents and rodent droppings were first observed in the facility kitchen approximately one to two months ago. Interviews with staff and outside sources revealed that the facility had a contracted pest control company that provided pest control services twice a month. Continued on LIC9099-C page... Unsubstantiated Staff stated that the pest control company would check and replace traps during the visit and interviews did not reveal concerns with the quality of work done by the pest control company. Review of pest control service reports from April to June 2025 revealed evidence of rodent activity in the facility kitchen which was first observed by the pest control company on 4/21/2025. During the pest control service on 4/21/2025, multiple dead rodents were found in rodent traps located within the kitchen ceiling and the pest control technician recommended duct inspection and the closure of any holes located in the kitchen ceiling to prevent future rodent activity. The facility was reinspected by the pest control company on 5/2/2025 with no evidence of rodent activity. On 5/19/2025, one dead rodent was observed in a trap located in the kitchen ceiling and the pest control technician stated that the rodent might have entered the building prior to sealing the exterior holes. On 5/27/2025, staff complained to the pest control technician that there was a foul smell in the kitchen and observed multiple dead rodents in a trap placed in the kitchen ceiling. The technician located additional openings in the adjacent laundry and maintenance room that could allow rodent access to the kitchen and recommended sealing those holes as well. The technician also recommended increasing the pest control service to once a week to deal with the rodent activity. On 6/2/2025, the technician observed one dead rodent in a kitchen ceiling trap. Interviews with an outside source did not reveal any concerns with the facility’s response to the discovery of rodents in the facility. The outside source also stated that the facility was following through with the pest control company’s recommendations to mitigate and preventing future rodent activity. LPA toured the laundry room, boiler room, and the facility kitchen during today’s visit and did not observe any evidence of rodent activity or droppings on the floor or in food storage areas. Dry food items were stored within plastic bins and elevated off the floor. LPA also toured the outside of the building and observed multiple areas including outside of the kitchen, laundry, and boiler rooms that had foam insulation sprayed into pipe fittings, duct work, and other openings to prevent rodent entry. Staff stated that new food containers were purchased to protect food supplies, and dry food items were stored in hard plastic bins to prevent rodent access. Continued on LIC9099-C page... Staff admitted that the rodent activity took time to be properly discovered due to the rodents primarily being in the ceiling, but staff did not reveal concerns with the facility’s response to the rodent activity. Interviews revealed that the rodent activity had decreased in the last month and rodents were only being found in traps in the kitchen ceiling. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Executive Director Jill McDonald, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jun 10, 2025 · control 08-AS-20250604090126

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an announced Pre-Licensing visit. LPA was met by Applicant Ferlina McBride and was granted entry into the facility. The purpose of today's visit is to inspect the facility to ensure that it is in compliance with California Code of Regulations, Title 22, Division 6. The fire inspection was completed on 10/17/2024 and the facility is approved for a total of 175 residents, 127 may be non-ambulatory and 48 may be bedridden. The facility is has one main building and two separate memory care buildings, and the facility is approved for delayed egress in the two memory care buildings. The facility has an approved hospice waiver for 50 residents. During today's visit, LPA toured the facility and inspected each building, including common areas, main kitchen, dining areas, common bathrooms and a random sampling of resident apartments and private bathrooms. The facility was found to be clean, safe, and in good repair with no pathway obstructions and was kept at a comfortable temperature. Common and private bathrooms were observed to be clean and the toilets and showers were found to be in working order. The facility's water temperature was randomly sampled in common and private bathrooms in each building and the temperatures were measured between 105 to 120 degrees Fahrenheit. LPA observed locked storage areas where all hazardous and/or toxic chemicals were stored and secured. LPA observed locked storage for resident medications. Fire extinguishers were observed throughout the facility and found to be in compliance. Functioning carbon monoxide detectors and smoke detectors were observed in the facility. No bodies of water were observed on the premises. LPA observed a 7-day supply of non-perishable food and a 2-day supply of perishable food located in the facility's main kitchen. Required postings were observed in the lobby of the facility. LPA reviewed facility’s Infection Control Plan, Emergency Disaster Plan, and a random sampling of resident and staff files. Continued on LIC809-C page... LPA conducted Component III with the applicant. The topics discussed were continuing operation requirements, record keeping/reporting, and physical plant compliance. LPA was away from the facility for approximately one hour between 12:20pm and 1:20pm. Pre-licensing is complete, and this facility has no deficiencies. It is recommended that this facility be licensed pending final review and approval. An exit interview was conducted with the applicant, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Oct 25, 2024