Ivy Park at Huntington Beach

Allegation investigated: Resident was overmedicated

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint investigation visit. Upon arrival, LPA Haddadin was greeted by Executive Director (ED) Bryan Reamer-Yu, who granted entry into the facility. LPA explained the purpose of the visit. The allegation was that “Resident was overmedicated.” The complaint indicated that Resident 1 (R1) was transported from the facility to the hospital on April 30, 2026, and was reportedly admitted for Digoxin toxicity. During the investigation, LPA interviewed four staff members and four residents, including R1. Four out of four staff members denied the allegation and denied having knowledge that R1 was administered medication in excess of the physician’s orders. Three out of three residents who were able to provide reliable statements denied experiencing or observing concerns regarding medication administration at the facility. LPA also interviewed R1. However, due to R1’s cognitive ability, LPA was unable to obtain a reliable statement regarding the allegation. {CONTINUE 9099C) Unsubstantiated During the interview and observation of R1, LPA did not observe any immediate health or safety concerns. LPA reviewed facility records, including an Unusual Incident Report (UIR) submitted by the facility to the Department. The UIR documented that R1 was observed to be lethargic and pale. Facility staff contacted 911, and responding paramedics evaluated R1. R1 was subsequently transported by ambulance to the emergency room for further medical evaluation and treatment. LPA also reviewed R1’s Medication Administration Record (MAR). The MAR documented that facility staff administered R1’s medications as prescribed by the physician. LPA did not identify any documentation indicating that R1 received an excessive dosage or that facility staff administered medication contrary to the physician’s orders. LPA attempted to contact the reporting party on May 7, 2026, using the contact information provided in the complaint. LPA was unsuccessful and was informed that no individual matched the name provided. LPA made an additional contact attempt on July 10, 2026, and was again informed that no individual matched the name provided. Therefore, LPA was unable to obtain an additional statement from the reporting party. Based on the interviews conducted, observations made, and records reviewed, there was insufficient evidence to establish that facility staff overmedicated R1. Although the allegation may have occurred or may be valid, there was not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation that “Resident was overmedicated” is Unsubstantiated.the state’s words, verbatim · CDSS document, Jul 10, 2026 · control 22-AS-20260504082152

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced case management visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by staff and explained the purpose of the visit. On July 14, 2025, the Orange County Regional Office received an incident report regarding an unwitnessed fall of Resident 1 (R1). The investigation determined the following: R1 was admitted to the facility on March 12, 2025. Per incident report, R1 had an unwitnessed fall on July 1, 2025 at approximately 12:30am. Staff last observed R1 at approximately 12:00am. R1 pressed on their pendant and staff found R1 on the floor. Staff called 911. Paramedics arrived at the facility and evaluated R1. Staff requested R1 to be transported to the hospital. Paramedics told staff R1 did not appear to be injured, assisted R1 back to bed, and left. At 7:30am, R1 complained of pain. Staff contacted non-emergency transport services and R1 arrived at the hospital at 8:15am. R1 was diagnosed with a non-operative, unspecified fracture of the left pubis, contusion of unspecified part of head, and fracture of unspecified parts of lumbosacral spine and pelvis. R1 returned to the facility the same day. Interviews with eight out of nine staff stated R1 was evaluated by the paramedics but declined to transport R1 to the hospital as their assessment did not indicate any injuries. The remaining staff stated they are aware of the fall and added there are two caregivers and one med-tech checking on residents at night. The Emergency Medical Incident Report narrative filed by Huntington Beach Fire Department dated July 1, 2025 determined R1 “had no apparent injury or medical complaint. (R1) assisted back to bed.” Although R1 sustained a fall, it remains unclear if the fall occurred as a result of neglect. Based on the investigation, the Department has concluded there is insufficient evidence to support the allegation staff neglected or failed to provide a sufficient level of care in R1 having an unwitnessed fall leading to a fractured spine and pelvis. Therefore, the allegation is deemed unsubstantiated. A copy of this report was reviewed and provided to Executive Director Bryan Reamer-Yuthe state’s words, verbatim · CDSS document, Jun 26, 2026

Allegation investigated: Facility staff are not meeting residents’ care needs due to lack of staff. Facility is billing for services not rendered.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on February 3, 2026. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Bryan Reamer-Yu. LPA explained the reason for the visit. This Department has investigated the complaint alleging that facility staff are not meeting residents’ care needs due to lack of staff. Regarding the allegation the following was revealed: During the investigation LPA reviewed the Ivy Park at Huntington Beach Evergreen staff schedule dated January 2026. Per staff schedule, on average there are three caregivers for the morning shift from 6:00 a.m. to 2:00 p.m., three caregivers for the evening shift from 2:00 p.m. to 10:00 p.m. and two caregiver for the night shift from 10:00 p.m. to 6:00 a.m. for 20 resident in care. Per May 2026 Evergreen staff schedule, on average there are three caregiver for the morning and evening shifts and two caregiver for the night shift for 21 residents in care. During the investigation LPA reviewed the Ivy Park at Huntington Beach shower schedule. Per shower schedule, CONTINUED ON LIC9099-C... Unsubstantiated Resident 1 (R1) is schedule to shower on Mondays and Thursdays. LPA also reviewed the Ivy Park at Huntington Beach Resident Care notes dated December 9, 2025, for R1. Per Resident Care notes, it states while trying to give R1 a shower, R1 became very violent and began hitting staff. During the interviews with residents, R1-R3 reported that staff are meeting their needs and/or stated that they have not developed a Urinary Tract Infection (UTI). During the interviews with staff, S1 reported that the facility has enough staff to meet the resident' needs. Per S2, sometimes R1 refuses to shower and stated that staff change the residents' diapers as needed. Regarding the allegation that facility is billing for services not rendered, the following was revealed: During the investigation LPA reviewed the Ivy Park at Huntington Beach Resident Assessment dated December 11, 2025, for R1. Per Resident Assessment, R1's Assessment Total is 178 points. LPA also reviewed the Fees for Additional Items and Services, Care Points and Levels of Care. Per Fees for Additional Items and Services, Care Points and Levels of Care, the fee for Level 2 (130-204 points) is $3,730.00 per month. LPA reviewed the Ivy Park at Huntington Beach billing statement dated January 19, 2026, February 18, 2026, and March 18, 2026, for R1. Per billing statement the Care Fees due for R1 is $3,730.00. During the interviews with staff, S1-S2 reported that the facility is only billing for services being provided. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with ED Reamer-Yu, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 6, 2026 · control 22-AS-20260203124016

Allegation investigated: Facility failed to get resident medical assistance in a timely manner

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Bryan Reamer-Yu, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that the facility failed to get resident medical assistance in a timely manner revealed the following: During the course of the investigation, LPA inspected the facility, interviewed (AD), Health Services Director (HSD) Rebecca Casella, residents, and witnesses, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Physician’s Report dated February 2, 2026, R1’s Individualized Service Plan dated December 11, 2025, R1’s Facility Care Notes, and R1’s Hospital Medical Records dated April 24, 2026. CONTINUED Unsubstantiated It was alleged that on April 24, 2026, R1 had an unwitnessed fall around 1:00AM and did not receive medical attention until 9:30AM when they arrived at an emergency room and were noted to have asymmetric pupils. LPA inspected the facility, conducted health and safety checks on residents including R1, and observed no health and safety issues. LPA interviewed R1 who raised no concerns with the care they are receiving at the facility. LPA interviewed AD who stated that R1 was sent to the hospital on April 24, 2026, due to a bruise on their right eye, returned to the facility the same day, and has been on more frequent checks since then. LPA reviewed R1’s Physician’s Report dated February 2, 2026, which indicates R1 has dementia, uses a walker, and is non-ambulatory. LPA reviewed R1’s Individualized Service Plan dated December 11, 2025, which indicates R1 is a fall risk. LPA interviewed HSD who stated that R1 is a fall risk based only on having dementia and using a walker, but R1 does not have a history of frequent falls. LPA reviewed R1’s Facility Care Notes which do not document any previous falls for R1. Per HSD, on April 24, 2026, during the overnight shift between 1:30AM and 2:00AM, R1 was noted to have redness under their eye, but the redness did not appear concerning, R1 did not complain of pain, and there was no evidence that R1 had had a fall so it is unknown what caused the redness. HSD stated that during the morning shift between 7:00AM and 7:30AM, R1 was observed with darker bruising under their right eye, did not complain of pain, paramedics were called, and although R1 did not complain of pain, the paramedics took R1 to the hospital because R1 was on blood thinners. Per HSD, R1 returned to the facility later that same day with no fractures and the only concern noted by the hospital was that one of R1’s pupils is larger than the other, but this has been the case since R1 was young due to an accident. LPA reviewed R1’s Hospital Medical Records dated April 24, 2026, which indicate R1 had no fractures or injuries other than a bruise on their right eye. LPA interviewed R1’s responsible party who confirmed R1 has had different sized pupils since before they moved into the facility and reported no concerns with how the facility handled R1’s eye injury. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 22-AS-20260424164805

Allegation investigated: Licensee did not issue refund to representative Licensee not responding to responsible party

On March 20, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Bryan Reamer-Yu was present and assisted on today's visit. During the course of the investigation, the Department interviewed staff, interviewed residents, interviewed witnesses, reviewed and obtained pertinent documents for this complaint. Regarding the allegation, Licensee did not issue refund to representative, the following has been concluded: It was alleged that the Licensee did not issue a refund to Person #1 (P1) representative. The Department conducted an interview with P1's representative, Witness #1 (W1). W1 stated that a cashier's check in the amount of $6,000.00 was provided to the facility by a different family member, who was not an authorized representative of P1. W1 said that the cashiers check was made on March 15, 2025, and that the cashier's check was for a deposit for P1 to move into the facility. CONTINUED ON LIC9099-C Unfounded W1 stated that he contacted the facility to return the cashiers check since it was not made by P1's authorized representative and since he had no intention of moving P1 into the facility. W1 confirmed that the facility did not deposit the cashiers check and confirmed that the cashiers check was returned to him by the facility on March 27, 2025. W1 also confirmed that P1 was never admitted into the facility and that an admission agreement was never signed by either party. The Department conducted an interview with the ED for this allegation. The ED confirmed that the facility did receive a cashiers check for P1 as a deposit for her to move in the facility. The ED stated that once they were informed that the cashiers check was not made by P1's authorized representative, it was not deposited and it was returned to W1 on March 27, 2025. The ED confirmed that P1 was never admitted to the facility and that an admission agreement was never signed by either party. Regarding the allegation, Licensee not responding to responsible party, the following has been concluded: It was alleged that the Licensee did not respond to P1's responsible party. The Department conducted an interview with P1's responsible party, W1. W1 confirmed that P1 was never admitted into the facility and that an admission agreement was never signed by either party. The Department also conducted an interview with the ED. The ED also confirmed that P1 was never admitted into the facility and that an admission agreement was never signed by either party. Since P1 was never admitted into the facility and since an admission agreement was not signed by either party, P1 is not considered to have ever been a resident at the facility. Since P1 was never a resident at the facility, the Licensee is able to respond to general inquiries by the public at their own discretion. Based on the evidence gathered during this investigation, the complaint is UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without reasonable basis. An exit interview was conducted with Executive Director Bryan Reamer-Yu and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2026 · control 22-AS-20250401131844

Allegation investigated: Neglect/lack of care and supervision resulting in resident sustaining a head injury

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, the Department interviewed staff as well as reviewed and obtained documentation such as UCI Hospital medical records. Regarding the allegation that Neglect/lack of care and supervision resulting in resident sustaining a head injury, the investigation revealed the following: Resident 1 (R1) was admitted into the facility on August 04, 2025, and was hospitalized twice for unwitnessed falls on September 09, 2025, and September 12, 2025. Facility assessments of R1 were conducted on August 03, 2025, and again on August 28, 2025, showing resident was a fall risk due to impaired vision but able to ambulate on their own. Individualized Service Plan dated August 08, 2025, lists R1 as a fall risk and advised staff to CONTINUED ON LIC 9099C DATED 01/16/2026 Unsubstantiated assist with cueing and maintaining a safe environment in the resident’s room as well as adequate lighting and proper footwear. Additionally, it was noted under “Behaviors” for staff to keep the resident with them during daytime hours and encourage activities. All staff interviewed indicated R1 was either in the common area with staff or checked at least every two hours if not in common area. Medical records obtained following R1’s hospitalization on September 09,2025, revealed they sustained a scalp laceration which was repaired with one staple. Imaging revealed no evidence of an acute traumatic injury. On September 12, 2025, after sustaining their second fall, medical records obtained revealed a small volume left frontal subarachnoid hemorrhage and an acute minimally displaced fracture of the left zygomatic arch. Upon return from the hospital additional fall preventions were put in place for R1 including a lowered bed; wheelchair; and a nighttime one on one care companion from the period of September 14, 2025, through September 23, 2025, for the hours of 10PM to 8AM. Staff interviewed reported that since the resident started utilizing the lower bed, there have been no other falls. The review of Huntington Beach Fire Department records showed staff called 911 to request medical assistance for both unwitnessed falls. The resident had three prior falls at the facility resulting in no injury for the dates of September 03, 2025; September 05, 2025; and September 08, 2025. Based on record review and interviews conducted, the Department is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator, and a copy of this report and confidential names list was provided to facilitythe state’s words, verbatim · CDSS document, Jan 16, 2026 · control 22-AS-20250909171225

Type of visit: Required - 1 Year

On the above-noted date, Licensing Program Analyst (LPA) Samer Haddadin conducted a required annual inspection of the facility. Upon arrival, LPA was greeted by Executive Director (ED) Bryan Reamer-Yu and explained the purpose of the visit. LPA, accompanied by Health Services Director (HSD) Rebecca Cassela, Maintenance Director (MD) Eddie Lopez, and the ED, toured the interior and exterior areas of the facility and observed the following: The facility is a two-story building that consists of forty-eight (48) apartment units designated for assisted living and forty-seven (47) apartment units within the memory care section. The memory care program operates across three neighborhoods located on the first and second floors of the main building, as well as in “The Cottage,” a separate building directly across from the main facility. The facility features four dining rooms, a bistro area, a television room, an activities room, a salon, and multiple outdoor patio areas available for residents’ use. During the inspection, LPA observed that all resident bathrooms were equipped with operational toilets and wash basins, and each contained appropriate safety features, including grab bars and non-skid surfaces in the showers. Common areas, including living rooms and dining rooms, were adequately furnished, provided sufficient seating, and appeared clean and well maintained. Water temperature measurements were taken throughout resident bathrooms and were observed to range between 107.4 and 119.9 degrees Fahrenheit, which is within the required regulatory range under Title 22. { ***CONTINUE 809C***} The facility’s fire alarm system was last inspected by a third-party contractor, Telgian, on June 27, 2025. Fire extinguishers were serviced and tagged by Fire Master on September 3, 2025. Documentation confirmed that an emergency drill was conducted on October 11, 2025. Emergency food and water supplies were reviewed and found to be fully stocked in compliance with Title 22 requirements, including a seven-day supply of nonperishable food and a two-day supply of perishable food items. LPA reviewed the emergency disaster plan and confirmed that the facility has submitted an updated Infection Control Plan as required. Medications are stored securely in locked medication carts, and the first aid kit was observed to contain all required items. Resident and personnel files are maintained in a locked and secure location. LPA reviewed five (5) resident files and five (5) staff files during the visit. All files were complete, containing the required documentation and signatures. LPA also observed reading materials, activity calendars, and recreational equipment in multiple locations throughout the facility, indicating an active program of daily engagement for residents. Outdoor areas were inspected and found to be shaded, well maintained, and easily accessible to residents in both assisted living and memory care areas. Based on observations made during the visit, the facility appeared to be in substantial compliance with applicable Title 22 regulations at the time of inspection. An exit interview was conducted with Executive Director (ED) Bryan Reamer-Yu, during which the findings of the inspection were reviewed and discussed. No deficiencies were cited during this visit. A copy of this report was provided to the Executive Director for the facility’s records.the state’s words, verbatim · CDSS document, Nov 3, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to gather additional information regarding complaint #22-AS-20250728145508. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPA interviewed staff as well as reviewed and obtained pertinent documentation such as progress notes for Resident 1. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 16, 2025

Allegation investigated: The signal system did not produce an auditory signal for staff causing a delay Staff did not provide care to residents in a timely manner

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the investigation, LPA toured the facility, activated emergency pull cords and interviewed staff. Regarding the allegations that the signal system did not produce an auditory signal for staff causing a delay and staff did not provide care to residents in a timely manner, the investigation revealed the following: LPA observed the signal system during the investigation. The system has a central base and emits to pagers on the caregivers. Pager goes off approximately every 5 minutes if not reset with an escalation to all management after 15 minutes. LPA pulled the emergency cord two different times and staff responded within 1 minute. Six out of six staff state they are provided with pagers and walkie talkies. Sometimes the pagers are in need of batteries and work once the battery is replaced. Facility management stated that there was a need to order more pagers and staff state currently working with new pagers. LPA reviewed the call response log CONTINUED ON LIC 9099C DATED 10/01/2025 Unsubstantiated LPA observed 12 response times over 19 minutes out of 319 responses reviewed and none were in the memory care unit. Six out of six staff state resident needs are being met and responses to the emergency pull are timely. Based on interviews conducted and records reviewed, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 22-AS-20250909100744

Allegation investigated: Staff did not prevent residents from sustaining falls while in care Facility did not ensure that there is adequate staffing to meet the needs of residents in care

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff. Regarding the allegations that staff did not prevent residents from sustaining falls while in care and facility did not ensure that there is adequate staffing to meet the needs of residents in care, the investigation revealed the following: Facility staffing runs 3 caregivers and a med tech for 1st and 2nd shift and 2 caregivers on NOC shift for each memory care area. LPA observed adequate staffing on two different occasions. Nine out of ten staff interviewed state resident needs are being met including all activities of daily living. Staff state showers are being given along with meal assistance in the dining room. LPA observed an order for liquid thickener for Resident 1 (R1). Staff state residents at a risk of falling are monitored carefully and each one has an individualized fall prevention plan including lighting and lower beds. LPA reviewed the call response log. CONTINUED ON LIC 9099C DATED 10/01/2025 Unsubstantiated LPA observed 12 response times over 19 minutes out of 319 responses reviewed and none were in the memory care unit. Staff confirm response times are timely. Based on interviews conducted and records reviewed, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 22-AS-20250728145508

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a health and safety check of the residents at the facility. LPA was greeted and granted entry by staff. LPA met with Administrator Bryan Reamer and Director of Wellness Rebecca Casella and explained the reason for the visit. LPA and staff toured the facility. LPA observed resident rooms have the required furnishings. LPA observed resident rooms are clean and organized. LPA observed resident bathrooms are clean and operational. Hot water measured between 111.5 and 112.8 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed no obstacles or hazards in the outdoor area. LPA observed residents participating in activities. LPA reviewed Resident 1 (R1)'s file. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 17, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Jenifer Tirre made an announced pre-licensing visit. LPA identified themselves and discussed the purpose of the visit with Executive Director Bryan Reamer-Yu. An initial application to operate a Residential Facility Care for the Elderly was submitted to CCL on 08/13/2024. There are 96 residents in care during today's visit. LPA observed facility is following infection control guidelines. LPA Tirre along with Executive Director Brian Reamer-Yu toured the facility at 7:55 AM and observed the following: Structure: Facility is a two story building housing 48 apartment units in the assisted living and 47 apartment units in the Memory care. Memory care has three neighborhood's on first and second floor of main building as well as The Cottage building directly across from main building. Facility offers four dining rooms, a bistro area, A Television room, activities room, and salon as well as outside patio areas. Living Room/ Dining Room: There is adequate seating and appropriately furnished areas for relaxation in Living room areas and adequate seating available in each dining room areas. Bedrooms Residents: All rooms toured are equipped with appropriate lighting, chair, night stand and ample closet space for resident belongings. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Emergency Phone Numbers and Exit Plan: Posted near entrance of facility. Food Service: Facility has ample perishable and non perishable food supplies. LPA observed posted menus throughout facility with multiple choices for residents. Smoke Detectors: Carbon monoxide detectors and Smoke detectors are tested in-house and documentation was provided by Johnson Controls. Documentation shows that 263 Smoke Detectors were tested operational and passed on last inspection date 12/18/2023. LPA observed 8 Fire extinguishers which were fully charged and accompanied by emergency flashlight. Toxins: Secured and inaccessible to residents in care. Water Temperature: Tested and recorded between 105.2 and 117.5 degrees F tested in both resident and common area bathrooms. Eight restrooms were tested during inspection visit Emergency Supplies: LPA observed ample emergency food and water stored on site in facility storage. CONTINUED ON LIC 809C LPA observed the emergency disaster plan and facility has submitted infection control plan as well.Medications, First-Aid Kit & Book: LPA observed first aid kit contained required elements. Medications are stored in locked medication carts. Facility has secured location for resident and personnel files Resident & Staff File: LPA reviewed 5 staff and 5 resident files during the visit. All files had completed documents. Reading Material, Games, and Equipment: LPA observed multiple activities calendars in multiple locations. Outside areas: LPA observed outside shaded areas for residents. Outside areas are easily accessible to residents in both assisted living and in memory care areas. Fire Clearance: Approved for 134 non-ambulatory residents and 8 bedridden residents on 8/12/2024. LPA observed the emergency chair adjacent to the staircase located on second floor. Facility has liability insurance on file for 5/1/2024 to 5/1/2025. Administrator's Certificate on file for Bryan Reamer-Yu Expiring 8/25/2026. The facility is ready to be licensed. Component III not conducted during visit due to facility Executive Director currently operating licensed facilities for the past twelve years. An exit interview was conducted with Executive Director and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 14, 2024