The Sea Bluffs

Allegation investigated: staff does not ensure residents are not recorded or pictures are taken by staff/vendors without residents consent

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted by staff and explained the reason for the visit. The Department received a complaint on June 18, 2026. LPA Mendivil obtained copies of vendor emails and as well as interviewed staff and residents. Regarding the allegation staff does not ensure residents are not recorded or pictures are taken by staff/vendors without residents consent, the investigation revealed the following: It was alleged that staff does not ensure residents are not recorded or pictures are taken by staff/vendors without residents consent. It was alleged that staff allowed an outside vendor to take videos on July 29th, 2024. Per interviews with 3 out of 3 staff, staff stated residents sign a consent for photos/videos when they first move into the facility. Staff stated if a resident did not consent for photos/videos to be taken they will honor the decision. Unfounded Interview with Activities Director, Activities Director stated that vendors are provided with facility expectations including treating residents with respect. Interviews with 4 out of 4 residents they stated that they have consented to photos or videos taken. 4 out of 4 residents stated that they actively and willingly participated in the facility's activities. 4 out of 4 residents stated they have not experienced any disrespect from entertainer or felt humiliated. Therefore based on the preponderance of evidence through records reviewed and interview the allegation staff does not ensure residents are not recorded or pictures are taken by staff/vendors without residents consent is determined to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 24, 2026 · control 22-AS-20260618095654

Allegation investigated: Staff allows the POA to dictate visitors for the residents

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into 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, LPA toured the facility and interviewed staff, resident and witnesses as well as reviewed and obtained pertinent documentation such as staff memo. Regarding the allegation that staff allows the POA to dictate visitors for the residents, the investigation revealed the following: On or around December 9, 2025, visitors attempted to visit Residents 1 and 2 (R1, R2) but were told to arrange the visitation through the Durable Power of Attorney (DPOA) and denied visitation. Two out of two staff, witness and visitor confirm visitation was to be allowed with DPOA approval only. Long Term Care Ombudsman visited the facility and advised visitation was to be allowed if residents were amenable to visiting. LPA interviewed resident during the visit who verbalized a wish for visitors. LPA reviewed facility staff email dated 12/11/2025 indicating "Effective immediately visitation was to be allowed for R1 and R2". Based on interviews conducted and record review, CONT ON LIC 9099C DATED 12/19/2025 Substantiated the preponderance of evidence standard has been met. Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 22-AS-20251212092124

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Jan 2, 2026

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their visitors, including ombudspersons.., permitted to visit privately during reasonable hours and without prior notice... This req is not met as evidenced by: Based on interviews conducted, Licensee failed to ensure R1 and R2 were allowed visitation. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: Licensee to provide an in-service on the powers entrusted to a DPOA and forward proof to LPA by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to deliver findings on an investigation conducted by the department. LPA was greeted and granted entry into the facility and explained the reason for the visit. On August 25, 2025, the Department received an incident report regarding Resident 1 (R1). The incident report dated August 21, 2025, reported R1 was found on the floor in the resident’s room complaining of severe pain and was transferred to Mission Hospital. A computerized tomography (CT) scan was done at the hospital and revealed a right-sided subdural hematoma along with a left-sided subarachnoid hematoma. During the course of the investigation, the Department interviewed staff, residents and witnesses as well as reviewed and obtained documentation such as medical records and death report. Per physician report dated May 20, 2025, R1 is diagnosed with Mild Cognitive Impairment and is non-ambulatory using a walker for ambulation. Facility assessment dated July 31, 2025, lists R1 as a moderate fall risk. Service plan dated January 11, 2025, indicates that R1 requires a fall management program. Director of Health Services states R1 was checked four times per shift due to the fall risk, but the facility does not document the checks. The resident had a prior fall reported to the Department on March 04, 2025. Per facility staff interviewed, the resident did not sustain any long term changes in condition following the fall and was still able to ambulate and transfer independently while utilizing a walker. On August 21, 2025, around 12:23 PM, R1 was observed by staff who had entered the room to advise it was time for lunch. R1 reported feeling dizzy. Staff reported R1 was left sitting in their recliner when staff had exited to bring R1 their lunch. When the staff returned two minutes later, R1 was on the ground with the resident’s head leaning on the dresser. 911 was called and resident was transported to the hospital. At the hospital, the R1’s condition deteriorated CONTINUED ON LIC 809C DATED 12/19/2025 due to the brain bleed. R1 had surgery on August 24, 2025, to release pressure due to the bleed, but the resident subsequently passed on August 25, 2025. The Orange County Coroner’s office conducted an investigation, and listed the death as accidental. Per the Coroner’s report, R1’s primary cause of death is listed as traumatic brain injury, sustained days prior to resident’s death with the secondary cause as fall, same level, sustained days prior to the resident’s death. Per the Department’s Interview with Orange County Coroner, there were no concerns of abuse, neglect, drugs, or alcohol. The Department interviewed R1’s primary care physician who stated that he did not believe the facility could have done anything different to prevent the fall and the facility does an excellent job of caring for residents. R1’s family member confirms satisfaction with resident’s care. Based on record review and interviews conducted, there was insufficient evidence to prove that the facility was neglectful or demonstrated a lack of care which led to the questionable death of the resident. Therefore, the allegation is deemed unsubstantiated meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 19, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 11/07/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87464(f)(1) pertaining to Basic Services has been cleared. Licensee provided proof of correction. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87204(a) Pertaining to Limitations has been cleared. Licensee provided proof of correction. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87203 Pertaining to Fire Safety has been cleared. Licensee provided proof of correction. Licensee has complied with the terms of the POC. Licensee has been advised to maintain compliance in all items previously cited. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 19, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to The Sea Bluffs. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is licensed for 88 non-ambulatory of which 10 may be bedridden. Facility has an approved hospice waiver for 15 residents and the facility currently has 9 residents on hospice care. Brent Broadhurst has an administrator certificate expiring on 08/09/2027. LPAs Lyman and Mendivil along with Business Office Manager Kenia Cabada toured the facility at 8:35 AM. Administrator Brent Broadhurst and Assistant Executive Director Haley Gmach joined the tour in progress. LPAs toured the physical plant, checked food service, facility records and the first aid kit. Facility appears to be clean, safe, and sanitary. Facility consists of three stories housing two memory care units and assisted living, multiple outside areas, two dining rooms, beauty salon, fitness area and movie theater. At approximately 8:45 AM, LPAs toured the first floor memory care unit and observed the delayed egress exit into the patio is chained shut from the outside (photo). It took several minutes for maintenance to unlock the door which is designated as an exit on facility floor plan. Resident apartments had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 107 and 116.4 degrees F in facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors as well as a first aid manual. LPAs observed cleaning supplies are secured. CONTINUED ON LIC 809C DATED 11/07/2025 Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors/ carbon monoxide detectors are tested quarterly in-house with the last inspection date of 10/16/2025. Fire inspections are conducted by an outside company, TRL Systems with the last inspection on 10/31/2025. Fire extinguishers are fully charged. LPAs observed evacuation chair at stairwell. LPAs toured the outside grounds and there is ample shaded seating for residents. LPAs observed ample emergency food and water. LPAs reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility conducts monthly emergency drills with the last drill conducted on 09/24/2025. Facility provides activities in the form of games, exercise, and outings. LPAs observed residents participating in activities during the visit. LPAs reviewed select resident and staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Residents #4 and #8 (R4, R8) are designated as bedridden per physician report. R4 resides in room 141 and R8 resides in room 238. Facility fire clearance indicates bedridden is not approved for those rooms. Staff files reviewed contained required documentation such as health screen/TB, required annual training and criminal record clearance. LPAs reviewed medication administration and storage. Medications are stored secured in medication carts. Medications appear to be administered per physician orders. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.the state’s words, verbatim · CDSS document, Nov 7, 2025

Type of visit: Case Management - Incident

On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and Kimberly Lyman made an unannounced visit to conduct a case management visit. LPAs were greeted and granted entry into the facility. The Department received an Unusual Incident/Injury Report on 10/30/2025 for an incident that occurred on 10/27/2025. It was reported that an alarm from the back door on the 2nd floor of Memory Care was heard by staff at 10:25am. It was reported that care staff went to check the door and no one was seen. Staff then conducted a head count and found out Resident 1 (R1) was missing. It was then reported staff went searching through the Memory Care building and surrounding neighborhood. It was reported at 10:33am R1 was found sitting on a bench outside of a residential home approximately .5 miles away from the facility. R1 was escorted back to the facility and checked for injuries. It was stated R1 did not complain of pain and no injuries were noted. R1's family was notified. The facility noted they have conducted in-service training for elopements and reporting. Per review of R1's physician report dated 05/20/2025 R1 is diagnosed with dementia and is not allowed to leave the facility unassisted. During today's visit LPA's tested delayed egress exit gate and no staff responded to the gate alarms. Based on observations made deficiencies are being cited per Title 22 Division 6 of California Code of Regulations. ,An exit interview was conducted and a copy of this report, LIC 809-D, LIC 811 Confidential Names LIC 421IM and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 7, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 8, 2025

Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by R1 was able to leave Memory Care and was found approx. .5 miles away from facility. This poses an immediate health and safety risk to persons in care. Civil Penalty Assessedthe state’s words, verbatim · CDSS document, Nov 7, 2025

Plan of correction: Facility conducted in service for elopements and reporting.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Fred Arias made an unannounced case management visit and met with Brent Broadhurst and Kenia Cabada . The purpose of today’s visit was to follow up on incident report received by the Department on August 25, 2025, reporting the death of resident 1 (R1). Per incident received, on August 21, 2025 at approximately 12:25pm, R1 was observed on the floor in their bedroom with their head next to their dresser cabinet. R1 complained of severe pain on their head and shoulder. 911 was called and R1 was transported to the hospital for evaluation. The facility received notice by law enforcement that R1 passed on August 25, 2025. During today’s visit LPA toured the interior and exterior of the facility and reviewed R1's file. LPA did not observe any immediate health and safety concerns during today’s visit. No deficiencies cited at this time. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 26, 2025

Allegation investigated: Staff inappropriately touched resident Staff handled resident in a rough manner Staff made inappropriate comments towards resident

Licensing Program Analysts (LPA) Jerome Haley made an unannounced visit to begin the investigation into the complaint allegations above. LPA Haley was greeted by staff and explained the reason for the visit upon entry. The complaint investigation consisted of interviews with staff, residents, a witness, and document review. Regarding the complaint allegation: Staff inappropriately touched resident During interviews 8 of 9 individuals denied the allegation. During an interview with resident 1 (R1), the resident said, I love it here! All the caregivers are very nice. Two additional residents were interviewed and neither resident had any complaints about the caregivers. Resident 2 (R2) says, the caregivers are okay and they come to assist R2 when needed. When the interview was over, R2 said, everyone here is very nice, including you. Continued on LIC9099C Unsubstantiated Regarding the complaint allegation: Staff handled resident in a rough manner During interviews 8 of 9 individuals denied the allegation. R1 completely denied the allegation until later on in the interview. When the interview with R1 was wrapping up, R1 revealed they apologized to one of the caregivers and said everyone has bad days. R1 was asked why they apologized and R1 explained that the caregiver is very popular, everyone likes the caregiver, and the caregiver is a very organized person. R1 explained the caregiver still comes and assist the resident during breakfast and there are no concerns. Regarding the complaint allegation: Staff made inappropriate comments towards resident During interviews 8 of 9 individuals denied the allegation. R1 completely denied the allegation. S3 denied the allegation and explained R1 coming up to them and apologizing to them. S3 also spoke to the family member of R1 and after speaking to the family of R1 and receiving an apology from R1, S3 says everything is fine now. According to S1, after receiving information on the alleged incident/situation involving R1 and S3, the family of R1 was contacted and informed of everything that allegedly happened. According to S1, the family of R1 has no concerns about R1 or the care being provided. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the 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 violations occurred; therefore, the allegations are deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 18, 2025 · control 22-AS-20250313145658

Allegation investigated: Staff accepted money from a resident

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegation. Findings are based upon this investigation which included interviews conducted, tour of the physical plant of the facility and copies of pertinent documents obtained. It is alleged that staff accepted money from a resident. Interview with staff 1 (S1) indicated that resident 1 (R1) had given them a monitory gift of $1000 dollars. S1 stated that they took the gift, but that they had not spent any of it. S1 indicated that they spoke with R1’s POA about the gift and POA gave S1 indications to hold the money until they came to visit R1 the following month. Interview with 3 of 3 staff indicated that it is company policy that no staff member is allowed to take any monetary gifts from any of the residing residents of the facility. Continued on LIC9099-C Substantiated Based on the information gathered the preponderance of evidence standard has been met, therefore, the allegation, facility staff is in disrepair, is found to be SUBSTANTIATED. Based on this inspection, deficiencies were observed at this time in the areas evaluated per Title 22 Division 6 Chapter 8 of the California Code of Regulations. See LIC9099-D for deficiencies. This report was reviewed with Administrator and a copy of this LIC9099, LIC9099-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.the state’s words, verbatim · CDSS document, Jan 27, 2025 · control 22-AS-20250122145257

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Feb 10, 2025

Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents' money... This requirement is not being met as evidenced by: base oon iterview with S1 they indicated that they accepted a monitary gift from R1. This presents a potential health, safety, and personal rights to resident in care.the state’s words, verbatim · CDSS document, Jan 27, 2025

Plan of correction: Executive Director agrees to review regulation section 87468.1 Personal Rights of Residents in All Facilities with all staff. Executive Director will send a signed statement of understanding along with a sign in sheet for all staff trained on the regulation section cited by POC due date of 2/10/25.

Type of visit: Required - 1 Year

On this day Licensing Program Analysts (LPAs) Fred Arias and Andrea Mendivil made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 88 non-ambulatory residents of which 10 may be bedridden. Facility has an approved hospice waiver for 15 residents and the facility currently has 67 residents, with 7 residents on hospice. Maintanance Director (MD) Pedro Ucros and Assistant Administrator (AAD) Haley Gmach arrived shortly to conduct facility tour. AAD Gmach has a valid certificate that expires on 8/10/2025. AAD provided updated liability insurance that expires on 7/01/2025. LPAs along with MD Ucros toured the facility at 8:30 AM with AAD Gmach joining shortly after. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 118.6 degrees F and 119.8 degrees F in checked restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPAs toured the kitchen on the first floor in memory care and observed sharps in a cabinet that was not locked. Continued on LIC 809-C dated 12/23/2024. The first floor kitchen in memory care also had toxins under the sink that were not secured due to malfunctioning cabinet doors. MD stated cabinet doors would be replaced and secured during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Some perishable food in the assisted living area kitchen was expired including milk, salad dressing, beef, and fish. Pork patties were observed to be on a kitchen counter kept at room temperature. Smoke detectors are tested quarterly by an outside party with the latest test recorded on 4/17/2024. Fire extinguishers were fully charged. LPAs reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility last conducted emergency drills on 7/31/2024. Outside grounds were toured. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise, arts and crafts, and group movie watching. There is shaded outdoor seating for residents. LPAs observed the emergency food and water supply. LPAs reviewed three resident files, three staff files, and ADD file. All resident files reviewed contained required documentation including admission agreements, physician reports, and resident appraisals. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. Medications are stored in a locked office on each floor. Medications are being administered per physician order. Based on the observations made during today’s visit, 2 deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Dec 23, 2024

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility is falsifying resident records

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into 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, LPA interviewed staff and witness as well as reviewed and obtained pertinent documentation such as facility form. Regarding the allegation that facility is falsifying resident records, the investigation revealed the following: Staff 1 (S1) was employed at the facility as the Memory Care Director. Facility form letter to physicians indicate S1 is an LVN. Review of California State Vocational Nursing Board does not have verification of licensure. S1 denies having an LVN license and indicates the form letter verbiage is an oversight. LPA conducted interviews with S2 and S3 and both deny any falsifying of resident physician reports. Document obtained by LPA indicate a conversation took place educating who can apporpiately fill out the physician report. Based on interviews conducted and record review, the preponderance of evidence standard has been met. Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, CONTINUED ON LIC 9099C DATED 09/24/24 Substantiated (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights.the state’s words, verbatim · CDSS document, Sep 24, 2024 · control 22-AS-20240918145738

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Oct 8, 2024

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This req is not being met as evidenced by: Based on record review, Licensee failed to ensure no false or misleading statements were disseminated. Facility form letter states S1 is an LVN when in fact the staff is not an LVN. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: Licensee to remove the false statement on facility forms and forward proof to LPA by POC due date.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Dwayne Mason Jr made an announced inspection to the facility for purpose of conducting a pre-licensing inspection for a change of ownership. LPA arrived at the facility and was greeted by Andrea Luther, Assistant Executive Director, Jill Libhart, Regional Director of Operations and Jenifer Larsen, Regional Director of Health Services. An application to operate a Residential Care Facility for the Elderly (RCFE) for (88) capacity, (0) ambulatory, (78) non-ambulatory, and (10) bedridden clients was received by Community Care Licensing (CCL) on 3/9/2022. Structure: The facility is comprised of two buildings. Building 1 is a three-story building. The first floor houses fourteen resident apartments, each with bathroom access, two offices, an open-use room, movie theater, medication room and communal bathroom. The second floor of Building 1 houses fourteen resident apartments, each with bathroom access, two activity rooms, computer room and two communal restrooms. The third floor of Building 1 houses eleven resident rooms, each with bathroom access, library, dining room and common bathroom. Building 2 is a two-story building. The first floor of Building 2 houses eighteen resident apartments, each with bathroom access, activity room, dining room, kitchen and medication room. The second floor of Building 2 houses twenty resident apartments, each with bathroom access, activity room, dining room, kitchen, medication and common area bathroom. LPA observed no sharps to be kept in any kitchen. Cleaning solutions and chemicals were locked in kitchen cabinets, laundry rooms and janitor closets. There are four laundry rooms across both buildings. LPA also observed locks on the doors to prevent resident access to kitchens, cleaning solution storage and laundry rooms. LPA observed the See Something, Say Something posters (PUB 475) mounted throughout the facility. There are two outdoor courtyards, one in each building. LPA did not observe any obstacles or hazards throughout facility. LPA observed fireplaces to be appropriately screened. Client Apartment: All resident apartments had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. There is a signal system on each floor of both buildings. Care staff on designated floors receive alerts from clients on their floor using the signal system. If Care Staff on the designated floor cannot get to the client requesting assistance, they can reach out to Care Staff on other floors via walkie-talkie to get assistance to the client in a timely manner. Medications, First-Aid Kit & Book: Medication is stored and locked in the various medication rooms throughout the facility. First aid kits have all the required elements and are stored in each medication room. Resident and staff files are stored in one of the medical file rooms. Fire Extinguisher/Smoke and Carbon Monoxide Detectors: LPA observed the fire extinguishers to be fully charged with service tags indicating they were last serviced on 10/16/2023. Smoke detectors could not be tested without alerting local fire authorities. Detectors were last serviced on 10/16/2023. Activities and Materials: The facility has a wide array of activities. These include but are not limited, fitness/wellness sessions, arts and crafts, puzzles, watercolors, books, virtual reality, games, a movie theater on site and planned outings. The facility also has a subscription to IN2L (It’s Never 2 Late) which is a service that empowers residents to develop and maintain their ability to use different types of technology. Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 8/8/2023. Bathrooms: All bathrooms have working plumbing. LPA measured hot water in sixteen bathrooms. Hot water in all bathrooms measured between 105 degrees Fahrenheit and 120 degrees Fahrenheit. Some bathroom temperatures briefly fluctuated outside of the 105-120 range, but all final readings measured between 105-120 degrees Fahrenheit. Regional Director of Operations stated they will have their maintenance person take a look at the water heaters as a precaution. Emergency Phone Numbers, Exit Plan, Menu and Food: Posted and available for review. There is a supply of 2-day perishable and 7-day of non-perishable food on hand. Based on today’s inspection, LPA has determined the facility is ready for their license. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 3, 2023