Claremont Manor.

Allegation: Staff do not meet a resident's incontinence needs It is alleged that the facility does not change R1’s diapers frequently enough, which is causing R1 to get urinary tract infections. During staff interviews, staff consistently stated that they assist R1 with ADLs, including grooming, showers, and incontinence care, and that residents requiring increased incontinence care are checked regularly. Staff stated that care provided is documented, including toileting and brief changes, and that staff respond to R1’s requests for assistance as promptly as possible. Staff stated that care plans and hospice plans are available and followed, and that care is individualized based on R1’s preferences and needs. Staff denied concerns of neglect and stated that R1 has not complained about incontinent care. During the resident interview, R1 stated that the facility provides her with everything she needs and that staff treat her well. R1 expressed satisfaction with her living environment and stated that her overall health is good. R1 stated she does not like hospice services and would prefer to return to her prior routine. R1 acknowledged the history of UTIs and reported she is currently taking antibiotics. During resident interviews, residents R2–R8 stated they are satisfied with the care being provided and reported no concerns regarding incontinence care. During W1 interview, W1 stated that R1 has resided at the facility for over eight years and expressed no concerns regarding the services provided. W1 reported regular communication with the hospice nurse and stated that a new incontinence care plan was developed to help reduce recurrent UTIs, noting that UTIs can be common with aging. W1 stated they will continue to communicate with hospice and facility staff and reported no additional concerns. During W2 interview, W2 stated their duties include assessing the resident, conducting regular check-ins, and coordinating care to support the resident’s comfort and well-being. W1 stated that R1 prefers care to be provided in a specific manner and that a care plan was developed between W2, R1 and W1. W2 stated that R1 has a history of recurring UTIs and that R1 reports feeling hot and experiencing burning sensations in the mornings. W2 stated that reminder signages are posted in R1’s room for caregivers to see and that care is adjusted to meet R1’s preferences. W2 described R1 as articulate, active in facility activities, and having vision impairment that causes occasional frustration. W2 stated their role is oversight and care coordination, with caregivers providing direct incontinence care per the care plan. W2 stated that they do not believe the facility neglects residents and would feel comfortable having their own family reside at the facility. Based on the investigation conducted, including interviews with staff, witnesses and residents and review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was held, and a copy of this report was provided.

Allegation: Staff do not meet a resident's incontinence needs It is alleged that the facility does not change R1’s diapers frequently enough, which is causing R1 to get urinary tract infections. Du ring staff interviews, staff consistently stated that they assist R1 with ADLs, including grooming, showers, and incontinence care, and that residents requiring increased incontinence care are checked regularly. Staff stated that care provided is documented, including toileting and brief changes, and that staff respond to R1’s requests for assistance as promptly as possible. Staff stated that care plans and hospice plans are available and followed, and that care is individualized based on R1’s preferences and needs. Staff denied concerns of neglect and stated that R1 has not complained about incontinent care. During the resident interview, R1 stated that the facility provides her with everything she needs and that staff treat her well. R1 expressed satisfaction with her living environment and stated that her overall health is good. R1 stated she does not like hospice services and would prefer to return to her prior routine. R1 acknowledged the history of UTIs and reported she is currently taking antibiotics. During resident interviews, residents R2–R7 stated they are satisfied with the care being provided and reported no concerns regarding incontinence care. During W1 interview, W1 stated that R1 has resided at the facility for over eight years and expressed no concerns regarding the services provided. W1 reported regular communication with the hospice nurse and stated that a new incontinence care plan was developed to help reduce recurrent UTIs, noting that UTIs can be common with aging. W1 stated they will continue to communicate with hospice and facility staff and reported no additional concerns. Based on the investigation conducted, including interviews with staff, witness and residents and review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was held, and a copy of this report was provided.

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced Case Management visit as a follow-up to a reported gas leak at the facility. The LPA met with Tanya Madrid, Director of Resident Services, and discussed the purpose of the visit. During the visit, the following documents and information were obtained and reviewed staff/resident roster, a map of the campus identifying the affected areas, plumbing work orders, a DigAlert invoice from the contractor to verify that planned drillings are being conducted safely, photos of drilling areas and the facility’s Emergency/Disaster Plan. During a case management visit, Steve Megyes, Director of Environmental Services and Tanya Madrid , Director of Resident Services provided the Licensing Program Analyst (LPA) with a tour of the affected areas related to the gas leak, including the Garden Apartments and East Way units. During the visit, the LPA observed that drilling activities had commenced, and the facility reported having a timeline for repairs to be completed by Friday, January 16, 2026. The LPA conducted interviews with two residents residing in the affected areas. Both residents appeared in good spirits and reported being minimally impacted by the gas leak. Residents stated that their units are equipped with heat pumps that allow for continued heating, and the units also have electric stoves, which remain functional. Residents reported being aware of the accommodation available to them, including temporary relocation options. One resident chose to temporarily relocate to another unit, though that resident also had access to a built-in pump for heating. The facility reported that it continues to monitor the repair process, conducts regular check-ins with affected residents, and address any additional concerns as they arise. The facility further stated that it will remain in contact with Community Care Licensing and provide ongoing updates regarding the status of repairs. There are no deficiencies observed during today’s visit. An exit interview was conducted and a copy of this report was provided.

Allegation: Staff neglected to report concern regarding resident The investigation revealed the following: It is alleged that facility staff failed to report a concern regarding R1. The complaint alleges that staff were aware of statements made by R1 indicating emotional distress and possible self-harm and did not take appropriate action to report. During staff interviews, staff reported that concerns regarding R1’s emotional well-being were first communicated by a private caregiver and were addressed once received. Staff stated the alleged self-harm statements were said to have occurred approximately two weeks earlier but were not reported by the private caregiver at that time. Staff reported that upon notification, supervisory and administrative staff were informed, R1’s safety was assessed, additional supervision was implemented, and R1 was referred for a mental health evaluation. Staff denied failing to report concerns and stated appropriate action was taken once the information was brought to the facility’s attention. During the resident interview, R1 stated she was feeling okay, expressed remorse for prior statements, denied any self-harm intent or behavior, and indicated she wished for the matter to be resolved. During the witness interview, the witness stated they have no concerns regarding the facility or the care provided to R1 and believed the facility responded appropriately to ensure R1’s safety. Community Care Licensing office received the self-harm report, and the facility submitted a detailed Special Incident Report (SIR) on 11/14/2025. Based on the investigation conducted, including interviews with staff, witness and resident and review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was held, and a copy of this report was provided.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted subsequent annual inspection on 8/01/2025. LPA Ramirez identified herself and was greeted by Director of Health Services- Minerva Naranjo and explained the purpose of the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Operational Requirements: The fire clearance is approved for (252) ambulatory residents and (108) non-ambulatory of which (18) may be bedridden. This facility may retain no more than twenty (20) hospice residents. There were seventeen (17) residents under hospice care during time of inspection. LPA Ramirez reviewed facility liability insurance and auto registration for three (3) facility vehicles. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed the required annual training for staff and staff working with dementia residents. LPA Ramirez reviewed food handler certificates for kitchen staff. Staffing: Administrator Certificate for Robert Barton (7033961740) expires 11/02/2025. See 809-C for continuation. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services. Resident Records/Incident Reports: LPA Ramirez reviewed Resident files for Resident #1 (R-1) through Resident #6 (R-6). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No violations were cited during this inspection visit. Exit interview was conducted. A copy of this report was provided.

Licensing Program Analyst’s (LPAs) Kimberly Ramirez, Blanca Gonzalez, and Sakinah Madyun conducted an annual inspection on 07/08/2025. LPAs met with Minerva Naranjo (Director of Health Services) and discussed the purpose of today’s visit. This facility is licensed to serve (252) ambulatory residents and (108) non-ambulatory of which (18) may be bedridden. There were two (2) bedridden residents receiving care during annual inspection. This facility may retain no more than twenty (20) hospice residents. There are fourteen (14) residents under hospice care, during annual inspection. Summer House Dementia Unit II is approved for (5) non-ambulatory residents with secured perimeter, locked gate and locked doors. There are currently twenty-two (22) residents in the Summer House Memory Care. The total number of residents at this facility is two-hundred and thirty-nine (239). See 809-C for continued report. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA’s observed carbon monoxide detectors and smoke alarms in hallways. Smoke alarms and carbon monoxide detectors were tested and observed to be operational. LPA’s inspected ten (10) rooms; of which five (5) in Summer House Memory Care and five (5) in The Lodge building of the facility. During inspection of Summer House Memory Care, LPA’s observed, combination locks on kitchenette refrigerators. Per Director of Health Services- Minerva Naranjo, resident#1 (R1) has a behavior of removing food or snacks from the refrigerator and placing the food item in random locations. LPA Ramirez will issue one (1) Technical Violation based on this observation. Director of Health Services- Minerva Naranjo instructed staff to remove all combination locks from Summer House Memory Care refrigerators. All resident bedrooms contained the required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observed postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez tested emergency pull cord in room#103 at 10:59am, and staff arrived at 11:01am. LPA’s observed evacuation chairs in stairways. Food Service: LPA’s observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with a maximum temperature of 40-degree F. (4 degree C). LPA’s observed facility weekly and daily menu, which is approved by the facility certified dietary manager. LPA’s observed kitchen staff preparing for lunch while wearing hair nets and gloves. LPA’s observed several dining room servers disinfecting tables and counters while wearing gloves and hair nets. SEE 809-C for continued report. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Planned Activities: LPA’s observed a calendar for July of 2025 with various activities and outings for residents. LPA’s observed sufficient outdoor space in both assisted living section and in memory care. Residents Rights-Information: LPA’s observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility computers with internet access and a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed evacuation chair in stairway. Last documented emergency drills were conducted on 7/01/25 during the AM, PM and NOC shifts. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez emergency food supply. Residents with Special Needs: Facility pool was observed to be inaccessible to residents with physical and mental disabilities. LPA’s observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA’s observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. Due to time constraints, LPA Ramirez will return at a later time to complete record review and interviews; required for annual inspection. No deficiencies were cited at this time. The Exit interview was conducted with Minerva Naranjo (Director of Health Services) and Administrator Robert Barton. A copy of this report was provided via email.

Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Gabriela Castro conducted an unannounced Case Management Visit-Incident on 05/20/2025, stemming from incident report received on 05/02/2025. LPAs were greeted by Director of Health Services-Minerva Naranjo and explained the purpose of the visit. Case Management findings: On 05/02/2025, LPA Ramirez received an Unusual Incident/Injury Report (LIC 624) regarding medication error that occurred on 05/01/2025. Per Unusual Incident/Injury Report (LIC 624) dated 05/01/2025, staff#1 (S1) erroneously dispensed another resident’s scheduled medication to resident#1 (R1). Staff immediately notified R1’s responsible party and R1’s primary care physician of the medication error. R1’s primary physician ordered facility staff to monitor R1’s blood pressure, report any abnormal results and skip AM medications till 05/02/2025. Facility staff later reported R1’s blood pressure to R1’s primary care physician and R1’s primary care physician deemed those results were normal. Facility staff reported R1 did not have any adverse reactions throughout 05/01/2025. According to Unusual Incident/Injury Report (LIC 624), S1 would be receiving in-service re-training on medication administration. On 05/20/2025, LPAs requested to review S1’s in-service training on medication administration completed after 05/01/2025. LPA’s reviewed completed in-service re-training for S1 with a final completion date of 05/07/2025. No deficiencies were cited today. Exit interview was conducted. A copy of this report was provided via email.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Minerva Naranjo (Director of Health Services), Tanya Madrid (Director of Resident Services) and Susan DeGange (Q&A Coordinator) and discussed the purpose of today’s visit. This facility is licensed to serve (252) ambulatory residents and (108) non-ambulatory of which (18) may be bedridden. There are eighty-two (82) residents under Assisted Living. There are zero (0) bedridden residents at this time. This facility may retain no more than fifteen (15) hospice residents. There are eleven (11) residents under hospice care. Summer House Dementia Unit II is approved for (5) non-ambulatory residents with secured perimeter, locked gate and locked doors. There are currently twenty-two (22) residents in the Summer House Dementia Unit. The total number of residents at this facility is 212. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected ten (10) rooms; of which five (5) in Summer House Memory Care and five (5) in The Lodge building of the facility. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez tested emergency pull cord in room#119. Staff responded 2 minutes later to assist. LPA Ramirez observed evacuation chairs in stairways. See 809-C for continuation. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). LPA Ramirez observed facility weekly and daily menu, which is approved by the facility certified dietary manager. LPA Ramirez observed kitchen staff preparing for lunch while wearing hair nets and gloves. LPA Ramirez observed several dinning room servers disinfecting tables and counters while wearing gloves and hair nets. Planned Activities: LPA Ramirez observed twelve (12) residents participating in a staff led seated exercise class in the Lodge Lounge room of the facility. LPA Ramirez observed a calendar for June of 2024 with various activities and outings for residents. LPA Ramirez observed sufficient outdoor space in both assisted living section and in memory care. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility computers with internet access and a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed evacuation chair in stairway. Last documented emergency drills were conducted on 5/3/24, 3/12,24, and on 02/27/24 during the AM, PM and NOC shifts. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez emergency food supply. Residents with Special Needs: Facility pool was observed to be inaccessible to residents with physical and mental disabilities. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. Due to time constraints, LPA Ramirez will return at a later time to complete annual inspection. No deficiencies were cited at this time. Exit interview was conducted with Minerva Naranjo (Director of Health Services), Tanya Madrid (Director of Resident Services) and Susan DeGange (Q&A Coordinator). A copy of this report was provided.

The investigation revealed the following: Staff do not provide a safe environment for residents. It was alleged that residents leave their walkers in the aisles and between tables in the dining room, thus creating safety hazards for other residents and servers. Interviewed nine (9) residents (R2 - R10) denied the allegation and stated that not seeing any residents leave their walkers in the aisles and between tables in the dining room. There are always staff in the dining room to monitor and ensure that residents walkers not blocking residents or servers way and they can navigate in the aisles and between tables. They stated that they didn't hear any complaints from the residents or staff about this matter. One (1) resident (R1) stated that they do not use the walker, just cane and in the dining room they put cane near the entrance wall. R1 stated they worry about others. R1 stated that staff made some arrangements in the dining room. They rearranged the tables in the dining room and now there are more empty spaces for residents to park their walkers. R1 will bring on Administrator's attention again if there will be any issues about this matter. Interviewed staff stated that there are always enough staff in the dining room to monitor residents. They stated they will ask residents and will move / rearrange walkers ensuring the walkways remain clear. During today's visit, LPA toured the dining room while residents were having lunch and observed the following: Residents walkers were observed parked outside of the dining room, next to the wall (near the dining area). Walkers were observed parked inside the dining area near the entrance wall and near the window wall, away from traffic. Multiple residents were observed having lunch while sitting in their wheelchairs, but this did not present a concern of blocking the walkways as there was ample space for the staff and residents to walk around. There was plenty of space for residents with walkers to navigate through. During today's visit, LPA did not observe walkers or wheelchairs obstructing the walkways inside the dining room and creating safety hazards for the staff and residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the Executive Director.

The investigation revealed the following. Regarding Allegation(s): Staff handled resident in a rough manner causing injury- It is alleged staff handled resident#1 (R1) in a rough manner causing injury. Five (5) out of the six (6) staff interviewed denied this allegation. Three (3) out of the three (3) residents interviewed denied this allegation. LPA Ramirez reviewed facility staff notes that indicated on 12/10/2023, R1 sustained an injury to R1’s hands and the injury was treated by staff. LPA Ramirez did observe other SIRs indicating R1 having injuries due to unwitnessed falls. LPA Ramirez reviewed nine (9) staff records. LPA Ramirez did observe facility policy on “Adult Abuse” for all staff in staff records. On 12/29/2023, LPA Ramirez received a letter from the facility stating an internal investigation conducted by the facility management did not substantiate this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Staff speaks inappropriately to residents- It is alleged staff speak inappropriately to residents. Five (5) out of the six (6) staff interviewed denied this allegation. Three (3) out of the three (3) residents interviewed denied this allegation. Facility tour conducted by LPA Ramirez on 12/29/2023, did not reveal staff speaking inappropriately to residents. On 12/29/2023, LPA Ramirez received a letter from the facility stating an internal investigation conducted by the facility management did not substantiate this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Staff put resident's mattress on the floor- It is alleged staff put R1’s mattress on the floor. Five (5) out of the six (6) staff interviewed denied this allegation. Three (3) out of the three (3) residents interviewed denied this allegation. On 12/29/2023, LPA Ramirez conducted a tour of R1’s room and upon entry observed R1 sleeping in hospital grade bed. LPA Ramirez observed a large blue fall pad on floor near R1’s bed. LPA Ramirez was told by staff that R1 has that fall pad placed on the floor due to R1 being a fall risk. Fall pad is being used to prevent further injury should R1 have another fall. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report was provided.

Resident interviews revealed that staff did not threaten residents for eviction. All seven (7) staff interviewed could not corroborate the allegation. Staff interviews revealed that staff did not threaten resident. File review revealed staff had policy that staff was not allowed to threaten residents. LPA reviewed resident’s letter dated 09/22/23 which resident claimed that letter was threatening to evict resident. The letter stated resident had violated facility policy about disclosing resident privacy in articles and published those in the newspaper without having residents' consent. Administrator attempted to stop resident from publishing articles of other residents without getting their permissions. The consequences of violating residents rights could be eviction per facility policy and resident's agreements. Therefore, staff did not threaten resident with eviction. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with the Administrator. A hard copy of the report and appeal rights were provided.

Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to complete the required annual inspection. The initial visit was conducted on 07/27/23. LPA met with Robert Barton (Executive Director) and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and completed the following domains: Staffing: There is sufficient staffing at the facility. Administrator Certificate for Robert Barton expires 01/31/25. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA reviewed staff files for Staff #1 (S-1) through Staff #7 (S-7). Pertinent staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. Staff have on-going training. Resident Rights-Information: Resident rights are posted and included in Resident files. Let-Us-No poster posted. LTCO poster posted. Resident Rights-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #8 (R-8). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. Refer to LIC 809C for the continuation of this report. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Physical Plant & Environment Safety: The kitchen, dining area, Summer House (Dementia) and The Lodge (Assisted Living) locations were amongst the toured locations. Smoke alarms and carbon monoxide detectors were observed throughout the tour. Fire extinguishers are located throughout the premises (service date of 04/22/23). Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Bathrooms had non-skid surfaces and grab bars. The swimming pool is gated and locked. Planned Activities: Staff provide a variety of activities for the residents. Activity calendar posted. There is a full-time Life Enrichment Director and Life Enrichment Assistants focusing on planned activities only. Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining room has adequate seating. Posted menu observed. Emergency water supply observed. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. Medications are administered as prescribed by the Physician. The facility provides incidental medical services. No deficiencies. Exit interview conducted, copy of appeal rights and a copy of this report was provided to Robert Barton.

Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Robert Barton (Executive Director) and discussed the purpose of today’s visit. This facility is licensed to serve (252) ambulatory residents and (108) non-ambulatory of which (18) may be bedridden. There are (56) residents under Assisted Living. There are no bedridden residents at this time. This facility may retain no more than (10) hospice residents. There are (7) residents under hospice care. Summer House Dementia Unit II is approved for (5) non-ambulatory residents with secured perimeter, locked gate and locked doors. There are currently 21 residents in the Dementia Unit. The total number of residents at this facility is 278. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for (252) ambulatory residents and (108) non-ambulatory of which (18) may be bedridden. There are no bedridden residents at this time. This facility may retain no more than (10) hospice residents. There are (7) residents under hospice care. Summer House Dementia Unit II is approved for (5) non-ambulatory residents with secured perimeter, locked gate and locked doors. There are currently 21 residents in the Dementia Unit. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Refer to LIC 809C for the continuation of this report. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The following domains remain pending: · Staffing · Personnel Records Training · Resident Rights- Information · Resident Rights-Incident Reports · Physical Plant & Environment Safety · Planned Activities · Food Service · Incidental Medical Services Exit interview conducted and a copy of this report was provided to Robert Barton.