The Chateau at River's Edge.

There building is three stories. There is one elevator in assisted living. Regional Maintenance, Jeff, confirmed the parts ordered are the elevator motor and pump. Maintenance Director, Tom Lowers (S4), stated elevator maintenance work is checked on a quarterly basis or as needed. On 2/25/26, LPA reviewed the copy of permit in elevator to see if it’s current and set to expire 5/15/26. LPA reviewed elevator maintenance record in which the last inspection date was 12/4/25, 11/3/25, and 9/17/25. LPA observed 'evac chairs' in each stairwell in which staff is trained to use and new staff will be training on. LPA observed the elevator is taped off and sigs informing the elevator is out of order are posted. The plan in place states there is signs posted informing the elevator is “Out of Order” signs has been placed on the elevators, a notice has been sent to all residents regarding the outage, meals are being offered in residents’ rooms for those who prefer not to go to the dining room, and care staff and Alpha One are assisting residents to and from the first floor as needed. On 2/25/26, LVN director of Assisted Living, Brittany Smith (S3), stated there are no non-ambulatory or bedridden residents residing on second floor and third floor.S1 and S2 stated programs and activities have been arranged on each floor to ensure continued engagement. Based on documents reviewed regarding elevator maintenance and LPA observation on The allegation "Facility elevator is in disrepair" is substantiated. The facility has ensured timely reporting, regular elevator maintenance, and there is a plan in place to ensure resident accommodation as repairs are undertaken. There are no deficiencies cited per California Code Regulation, TITLE 22. Exit interview was conducted with S1. LIC 9102TV and a copy of this report was left at the facility.

On 10/16/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct the annual inspection.  LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator / Executive Director (ED).  LPA met with Marianne Richardson and a brief interview followed. LPA observed 9 residents eating breakfast in the dining room being attended to by 2 servers.   LPA and ED continued on into the kitchen which was inaccessible to residents in care. LPA observed that kitchen staff were wearing appropriate clothing, gloves, and long hair was secured appropriately at the time of the inspection. LPA inspected inventory of food and found it to be sufficient for 7-day perishable and 2-day non-perishable. LPA reviewed storage and dating procedures with the chef. LPA also observed the fire extinguishers were last inspected on 10/30/24 by Johnson Controls. The ED and LPA proceeded to visit 2 resident rooms in assisted living. All had the required furniture, furnishings and lighting to be in compliance at the time of this inspection. LPA inspected the bathrooms and observed hand soap, towels and trash cans along with grab bars and non-slip/skid surfaces in the showers. LPA measure the hot water in room 131 to ensure it was between the required 105 - 120 degrees Fahrenheit. The hot water measured 109.6 degrees and was in compliance at the time of this inspection. LPA activated the call alert/pendant in room 131. Staff responded in 2 minutes and 13 seconds. LPA and ED inspected the Medication Room. LPA reviewed the administration, storage and destruction procedures and compared the physical pill package for one of the resident's medications to ensure it matched what was logged in the electronic medication recording system. LPA also inspected the first aid kit 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 to ensure it had all the required elements. While touring the facility, LPA observed 6 residents in assisted living participating in a morning fitness class in an activity room led by a staff member.  Later in the tour this LPA observed 7 residents present for the morning exercise class in memory care being led by the fitness instructor and supervised by 2 memory care staff and the Assisted Living Director. The following materials were posted in the facility: "If You See Something, Say Something" and Ombudsman contact information posters, Resident Rights, grievance policy, calendar of activities, facility menu, and facility license. The ED and the LPA then inspected the exterior of the facility. All screens and gutters were in good repair at the time of this inspection. There was a fenced in garden area in memory care with shade and furniture for residents to enjoy. The front of the facility had a shaded area with furniture for residents in the assisted living area to enjoy. A file review was then conducted by the LPA. The staff roster was reviewed to ensure that all 84 employees had the required background clearances. All were in compliance at the time of this inspection. Files were then reviewed for 3 staff and 2 residents. LPA provided technical assistance regarding training requirements for CPR and First Aid.  LPA reviewed that servers in the dining room under 18 years of age must be supervised by someone with caregiver and/or medication technician training in case of emergency. According to the California Code of Regulations, Title 22, no deficiencies were cited during today's visit, a copy of this report was provided and an exit interview was conducted with Marianne Richardson.

Facility staff interviews demonstrated staff were aware of resident’s wounds on thighs and had communicated with home health agency on 8/4/23 that was already providing wound care for R1 for preexisting wounds. As all community care licensed facilities are non-medical, facility staff were not trained to provide wound care and provided documented outreach to home health agencies responsible for wound care. Home health did not diagnose the injuries to R1’s thighs as pressure injuries but as “trauma skin injury”. Facility and home health records indicate Home health visits for wound care occurred on 8/7/23, 8/9/23, 8/14/23, 8/15/23 and 8/18/23. Prior to R1 being sent to the hospital for treatment on 8/21/23 the facility provided multiple attempts at reaching R1’s home health agency for wound care as documentation in facility records indicate the staff members did not believe the wounds observed were healing and were deteriorating per facility notes for R1. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of neglect/Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.

On 12/10/24 at 3:45pm, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case management inspection to observed and photograph a resident bedroom. LPA met with administrator Marianne Richardson and together toured the facility and room. LPA obtained photographs of the former resident's bedroom identified as G10. Per California Code of Regulations, Title 22, there are no deficiencies cited during today's inspection. Exit interview conducted and a copy of this report was left at the facility.

Continued from LIC 9099 According to an interview with the reporting party (RP), the facility elevator has broken down 12 times. Recently, the two times the elevator broke down, it was down for 10 days.  For the individuals on the second and third floors of the building, they were not able to go down to the first floor. The facility would bring up the food to the residents. By the time, the resident received the food, it was cold.  If a resident were to call for assistance with  Activity of Daily Living (ADL), the resident had to wait 45 minutes to respond too the call. The RP expressed concern of if there was a fire, all residents on the second and third floor would end up dead. RP stated there is not enough man power or time to get residents out safely. In December of 2023, the roof leaked and fell down while the RP and resident was eating lunch. The RP provided pictures of the roof being in disrepair. On 04/03/2024, LPA Kimberly Viarella observed the facility. LPA observed the main dining room in Assisted Living (AL) was closed as the ceiling is being repaired and other updates were in the process of being completed. According to an interview with the Dining Room Manager, the elevator was repaired on 03/29/24 after being out of order for 8 days. It went down at 3:00 PM on 03/20/24, and came back into operation at 3:20 PM 03/28/24.  LPA Viarella learned that Alpha One Ambulance Medical Services keeps an office at the Chateau at River's Edge, in the Independent Living (IL) portion of the facility. They were on call to assist with transporting residents up and down the stairs as requested.  During that time, staff received stair chair training so that they were also able to assist residents in moving between floors while the elevator was out of order. On 04/15/2024, LPA Victoria Brown conducted a complaint investigation for a separate complaint (27-AS-20240411120832) regarding an allegation of staff does not prevent facility roof from leaking. LPA Brown learned the facility secured a contract with Sonray Construction to fix the roof in November of 2023. Due to weather conditions, the construction was delayed. To ensure safety, dining for residents were moved to another area. Resident rooms were not affected. Finding was determined unfounded. On 05/23/2024, LPA Valerio observed the facility. LPA Valerio observed the dining room and kitchen to be closed off from residents as it was under construction. LPA Valerio also observed the elevator to be in working condition. Continues on LIC 9099 - C, page 3 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 Continued from Page 2, LIC 9099- C On 07/09/2024, LPA Valerio observed the facility. LPA Valerio observed the construction to be completed in the dining room and kitchen. The elevator was observed to be in working condition.  The elevator has an active permit issued by the Department of Industrial Relations - Division of Occupation Safety & Health. The inspection was on 02/13/24 and the permit expires 02/13/2025. LPA Valerio reviewed elevator log records. Elevator records show the elevator had a trouble call to TK Elevator 14 times throughout February 2023 to November 2023. The TK Elevator Repair, Test, and Callback Log showed entry dates for 02/13/24, 02/27/24, 02/29/24, 03/08/24, and 03/28/2024. During their hydraulic maintenance task log, it was completed during February 2024. LPA Valerio interviewed Administrator Marianne, which corroborated statements discussed with LPA Brown and LPA Viarella. Administrator Marianne started as the administrator in January of 2024. When the elevator went down in March, the facility used TK Maintenance, which was the maintenance company used prior to Administrator being brought in. Due to the last occurrence, another elevator company was sought out to service and provide maintenance to the facility elevator.  Administrator stated they had round the clock staff and Alpha One to assist residents up and down the stairs. They have 3 chair lifts. Alpha One has a station right at the facility, so they are always here. When it first happened, they sent out two crews to assist us because it was during meal time. The chair operates with the help of two staff. Residents had the option to dine in their room, dine upstairs in the common area on the floor, or dine down stairs. The facility turned the activity room and another common area into dining areas. Meals could occur on the first, second, and third floor of the facility. Restaurant crew was bringing hot plates to room and carrying hot trays up and down all the stairs. They made sure socialization was still happening, people were getting fed, and people were getting what they needed. They also brought programming to each level so residents were not confined to their rooms. Administrator stated there was never a time where someone was stuck up there. Continues on LIC 9099 - C, Page 4... 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 Continues from Page 3, LIC 9099 - C R1 recalled the incident of when the elevator went down. The staff would assist R1 by taking R1 to the back stairs. R1 stated it was 2 sometimes, maybe 3 staff that helped R1 down the stairs. R1 uses a walker. R1 would go down anytime R1 wanted to go there. It was mostly for meals. R1 said they offered bingo when the elevator was down. They offered to bring meals up to the room. R1 preferred going downstairs because the plates were hotter. When eaten upstairs, they were warm. They were not cold but not extremely hot. Staff would take about 10 - 15 minutes to get to R1's room. R1 stated R1 was never stuck upstairs. R2 has been a resident since December of 2023. In December, things were different compared to how they are now. In December, staff would take 45 minutes to an hour to respond to R2's call. Currently, staff take 10 - 15 minutes to respond to calls. R2 stated it was due to staff shortage. R2 recalls a time where a staff was shadowing one day and then the next day the staff was on their own. R2 believes that staff need additional training to care for residents, there needs to be better communication between management and residents, and staff/residents need to be trained on emergency evacuations. R2 stated there have been no fire drills since living at the facility. R2 stated the elevator breaks down on a regular basis. Staff brought everything to R2, meals and activities included. According to R2, staff made it work. R3 stated R3 was never stuck upstairs, is independent, and remembers staff bring meals to the room. R3 stated it took about 20 minutes for staff to respond. R5 stated on weekends, it takes staff longer to respond, possible due to being short staff. Staff take 30 minutes or longer to respond to calls on weekends compared to right away to 10 minutes on the week days. R5 stated the elevator has always worked, feels safe, and says staff treat them well. Continues on LIC 9099 - C, Page 5 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 Continued from Page 4, LIC 9099 LPA Valerio interviewed five (5) staff, Staff 1 (S1) - Staff 5 (S5). S1 works morning shift. S1 says it takes staff about 5 to 10 minutes to respond to resident call. If they are short, they work together to make sure they get to all the residents. S2 stated there is 5 - 6 staff on shift, sometimes 7 staff to directly care for the residents. S2 typically does immediately to help residents if S2 sees a call. If S2 is busy, S2 will use the walkie talkie to get someone else to respond to the call. S2 takes time with the resident and does not want to rush so they can get what they need. S2 does not recall a time when the elevator went down. S3 stated response time depends on how many staff are on shift and if the person is available. S3 stated it could take anywhere from one minute, five minutes, to fifteen minutes. S3 stated they use a Tablet aerial system for resident pendant calls to see who is calling and Carestream is used to document ADLs. S4 stated there are times where things are not working, but the facility gets them fixed. S4 feels there is enough staff on shift to care for the resident. S4 takes less than 5 minutes to answer the call lights. When the elevator broke down, staff brought everything upstairs, including meals. S5 stated training has been given for emergency evacuation, general orientation, and e-learning. S5 used the "special wheelchair" to get the residents down when the elevators were not working. S5 stated they needed two people to assist and it would not take long because they worked together. S5 answered call lights immediately. S5  stated we have to make sure we answer right away. Just in case they use the restroom or they want to get up, we do not want them to fall. When S5 is busy, S5 uses the radio to call for someone to help. S5 stated there is not a time where staff do not respond right away. Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited.  An exit interview was held and a copy of report was given to Executive Director/Administrator Marianne Richardson.

Allegation: Facility director made inappropriate decisions for a resident to be placed at a different facility where the staff member later became a director. Throughout this investigation, LPA conducted interviews with facility staff, former staff and Power of Attorney (POA) representatives. Additionally, LPA conducted a review of resident files. According to interview with the POA representatives, the decision to relocate R1 was based on the need for a higher level of care which the assisted living could no longer provide. POA representatives further explained that R1 needed to be place in memory care based on current assessment of R1’s Behavior Therapist. The interviews further disclosed that while considering alternative placements at other facilities, the decision to move R1 to current facility was influenced by the recommendation of the former administrator, who had a positive relationship with R1. Additionally, it was clarified that the move was primarily driven by the need for memory care, which was not available at Chateau's at Rivers Edge at the time. Interview with current administrator confirmed that R1's relocation was necessary due to the requirement for memory care, which Chateau's did not offer at the time of the decision. Review of R1’s care notes revealed that on 12/19/23, R1’s behavior therapist had informed facility staff that R1 is not suitable for the community (Assisted Living) due to R1’s cognitive state. Based on that, further review revealed that on 12/20/23, POA representative for R1 contacted the facility informing them that POA will be putting in 30-day notice for R1. Based on all gathered information, the Department concluded that the allegation of inappropriate decision-making by the facility director regarding R1's relocation to a facility where they later became director is UNFOUNDED. The decision was justified by the resident's care needs and available placement needed at that time. {Page 2/4} 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 Allegation: Staff coerced a dementia resident into signing documents. The investigation into the allegation that staff coerced a dementia resident (referred to as R1) into signing documents involved staff interviews and document reviews. According to an interview with staff, R1 demonstrated awareness of what they were signing at the time. Staff further noted the presence of a Notary Public during the signing of documents to assess R1's capacity to understand and consent to the content of the documents. Additionally, R1's accountant was present, providing further oversight. Review of Notary Public documents dated July 5, 2023, and October 4, 2023, confirmed R1 signed the documents in the Notary Public’s presence, verifying R1's identity and confirming that R1 executed the documents willingly and in their authorized capacity. Additionally, review of R1’s Physician Report (LIC 602A) dated January 23, 2023, indicated R1 was diagnosed with Mild Cognitive Impairment but retained the ability to follow instructions and communicate needs. Based on these findings, the Department concluded that the allegation of staff coercion of the dementia resident into signing documents was UNFOUNDED. The presence of a Notary Public, R1’s awareness during the signing process, and their ability to communicate needs supported the conclusion that the documents were executed voluntarily and in accordance with R1's capacity. {Page 3/4} 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 Allegation: Staff billed a resident for two rooms at the same time. Throughout the investigation conducted by LPA, interviews and record reviews were conducted to address allegations concerning billing discrepancies for resident (R1). Review of R1's ledger from November 2019 to March 2024 revealed specific transactions. R1 was charged at the Independent Living unit for January 2023 on 12/21/22 and was credited partially for January 2023 on 1/23//23. Additionally, R1 was last charged at the Independent Living unit on 1/23/23, for the month of February 2023, but was credited the same amount immediately. Subsequently, on 1/23/23, charges appeared for R1 at the Assisted Living unit for the month of February 2023 and for part of January 2023. In an interview with the current Administrator, it was clarified that despite R1's belongings remaining in their Independent Living unit for nearly a year, R1 was not billed twice for occupancy. Based on the gathered information, the Department concluded that the allegation of staff billing resident for two rooms simultaneously was UNFOUNDED. The investigation confirmed that billing was handled appropriately, with no evidence supporting the claim of improper charges. Note that an unfounded finding means the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Marianne Richardson, Executive Director/Administrator, and a copy of this report was provided. {Page 4/4} 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 This practice ensures that residents who require assistance are properly attended to during their mealtime and returned safely to their designated living area afterward. It was noted during interviews that Independent Living residents do not receive direct staff assistance as they are more independent, whereas Assisted Living residents receive necessary escorting. The investigation also referenced a documentation from R1’s Physician Report and Service Plan, which confirmed R1's need for extensive assistance and their inability to independently manage self-care due to cognitive impairment and physical limitations. Based on the gathered information, the Department concluded that the allegation that staff did not allow R1 to dine in the dining room of their choice was UNSUBSTANTIATED. The procedures in place, including escorting R1 and other residents when requested, were deemed appropriate given R1's care plan and safety needs. Note that an unsubstantiated finding means 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. An exit interview was conducted with Marianne Richardson, Executive Director/Administrator, and a copy of this report was provided. {Page 2/2}

Sonray Construction began the roofing work, however, Paragon Construction is completing the additional scope of work required by the Engineer for the permit. A copy of the Paragon Construction contract dated 3/28/24 which was initiated 3/26/24 was provided. The inside areas of the dining room such as the carpet, mold inspection, painting will be completed within the next 2 weeks. An incident report was submitted to Community Care Licensing (CCL) as well. A report of completion shall also be submitted to CCL. Based on interviews and a review of documentation the allegation is deemed Unfounded. "The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint." Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided.

{Con't from LIC9099} Per review of the contract, the scope and nature of the work includes roaches, common ants, rats and mice. Further review indicated that the frequency of the service is once a month for a period of one year. During facility observation of the outside perimeter of the facility, LPA noted rodent bait stations placed around the building. Based on observation, interviews and record review, there is not a preponderance of evidence to conclude that the facility staff are not addressing vermin in the facility. Therefore, this allegation is UNSUBSTANTIATED. Allegation: Staff are not keeping the facility free from odors from incontinence. This investigation consists of observations. This LPA conducted facility observations during the following visits on 11/30/23 and 12/13/23. During these visits, LPA did not notice odors from incontinence. This facility was also visited by other LPAs on 12/14/23, 11/20/23. 10/02/23 and 9/28/23. During these visits, LPAs did not note in their reports of any odors from incontinence. Based on information obtained, there is not a preponderance of evidence to conclude that the facility staff are not keeping the facility free from odors from incontinence. Therefore, this allegation is UNSUBSTANTIATED. An exit interview was conducted with ______ and a copy of this report and appeal rights were provided.

The administrator said the elevator was not used over the weekend to prevent anyone from getting stuck inside. The administrator said the elevator was available for use for emergencies, if needed. The administrator said the elevator was repaired on November 13, 2023. The administrator said that meals were delivered to any residents who did not want to come downstairs. LPA Moleski reviewed an email sent by the former facility administrator to the Community Care Licensing Division on November 12, 2023. In the email, the administrator said the elevator was having “technical issues,” and that “we are able to use it” but “we made an executive decision to not use it until it can get fully repaired on Monday [November 13, 2023]”. LPA Moleski reviewed a work report from an elevator maintenance company. The report details service through the period of November 11, 2023 and November 15, 2023. According to the report, the elevator buttons were lighting up but would then turn off as of November 11, 2023. The report describes service being performed on November 13, 2023. The elevator had returned to service as of November 15, 2023, according to the report. LPA Moleski interviewed four staff members (S1-S4). In an interview, the facility maintenance director (S1) said S1 was first aware of the elevator issues as of November 10, 2023. At that time, the elevator’s button lights would turn off after being pressed, but would work if pressed repeatedly. According to S1, an elevator maintenance company was called on November 11, 2023. S1 said the elevator was fully operational as of the morning of November 14, 2023. LPA Moleski interviewed four residents (R1-R4). In an interview, R1 said food was delivered while the elevator was not being used. R1 said staff were “very good” about delivering food. R1 said R1 had no concerns regarding the food service while the elevator was not being used. LPA Moleski reviewed food service sheets dated between November 11, 2023 and November 13, 2023. According to the sheets, R1 was not served any meals during this time. In an interview, R1 said R1 had some food delivered, and said R1 had plenty of food in R1’s room. LPA Moleski reviewed R1’s LIC 602. R1 is ambulatory, according to the LIC 602. [continued on 9099-C] 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 In an interview, the facility’s dining room manager (S2) said that R1 often refuses meal service, and that R1 prefers R1’s own food. S2 said there were no issues with food deliveries during the time the elevator was not being used. In an interview, S3 said there were no issues getting meals delivered to residents on November 12, 2023. S4 did not recall any issues with food service on November 13, 2023. In interviews, R2-R4 did not share any concerns regarding food service during the time the elevator was not being used. R3 said R3 was helped downstairs by a friend, and said that the elevator was available for use for emergencies. R3 said R3 used the elevator while it was not in general operation. R4 said R4 was carried upstairs in a wheelchair by paramedics while the elevator was not being used. The department has determined the following as it relates to the allegations that the facility elevator is in disrepair and that facility staff do not provide adequate food service to residents in care: Based on interviews, observation, and record review, the above allegations are UNSUBSTANTIATED, which means 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. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Vuittonet.

On 9/12/23, elevator repair company informed the facility that all circuits boards would need to be replace due to older boards no longer being supported and not capable of communicating with newer boards. There was a delay in repair due to waiting for the boards to arrive. Based on records reviews, the facility contacted elevator repair immediately upon being aware of the issue. LPA observed that the facility had done everything to remedy the problem. Moreover, it was learned that the same elevator was out of service for four days in May 2023. LPA Gould unsubstantiated the allegation of elevator is in disrepair on 8/10/2023 by Complaint Control Number: 27-AS-20230501114110. Regarding the allegation that facility staff failed to serve meals in a timely manner, LPA reviewed records and conducted interview with 7 residents and 4 staff members. Based on staff interviews, staff stated that when the elevator was out of service, it does take a bit more time for food to be delivered. However, staff informed that all residents were receiving meals in a timely manner. Staff denied having knowledge of any resident who was provided meals late. Based on resident interviews, 5 out of 7 residents stated that meals were provided timely. LPA interviewed resident (R1), R1 stated that she receives all her meals in a reasonable time. As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of the report was provided.

Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual continuation inspection on 10/02/2023 at 8:00 AM. LPA Martinez met with Elena Cuevas and stated the purpose of today’s visit. LPA Martinez inspected the physical plant of the facility to ensure compliance with Title 22 regulations. The facility is licensed for 26 ambulatory residents and 116 non-ambulatory residents, which 10 may be bedridden. In addition, the facility has an approved hospice waiver for 15. There are currently 86 residents who reside at this facility. LPA Martinez toured the facility with Elena Cuevas on 10/01/2023 at 9:30 AM. During today's visit, LPA Martinez toured the memory care unit, and the memory care unit census is 9. LPA Martinez reviewed the fire inspection report with Elena Cuevas. Elena Cuevas and LPA Martinez toured the exterior of building and fire sprinkler system. During the tour, LPA Martinez and Elena Cuevas visited the pond area. Elena Cuevas reported the pond was three feet deep. During 09/28/2023 initial annual visit, LPA Martinez reviewed medication administration records, staff files, resident files, toured the facility, inspected the kitchen, and inspected fire extinguisher tags. 09/28/2023 deficiencies can be found on the annual 09/28/2023 809 report. In addition, LPA Martinez reviewed administrator change request documentation. The Department will continue to follow up with process of Elena's administrator certificate renewal request. As result of today's visit, there were no deficiencies cited. An exit interview was conducted, and a copy of this report was provided to the facility.

Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 09/28/2023 at 8:30 AM. LPA Martinez met with Chelsea Xiong and stated the purpose of today’s visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. Administrator holds current certificate. The facility is licensed for 26 ambulatory residents and 116 non-ambulatory residents, which 10 may be bedridden. In addition, the facility has an approved hospice waiver for 15. There are currently 86 residents who reside at this facility. LPA Martinez toured the facility with Karla Rocha on 09/28/2023 at 2:30 PM. Due to insufficient time, the annual will require a continuation visit. The Department will return at a later date to complete the annual inspection. However, at today's 09/28/2023 annual inspection the following deficiencies were observed: Nine out ten employees were missing first aid certificates. Kitchen freezer measured at 10 degrees. Kitchen refrigerator measured at 47 degrees. Resident 1 (R1) is on a special diet (Gluten Free) However, facility kitchen staff was unaware of special diet and facility staff reported resident 2 (R2) is also on a glutin free diet. The facility has not implemented a glutin free plan. Pond/large body of water procedures are being reviewed by LPA Martinez. As a result of this annual inspection, the following deficiencies can be found on the 9099 D page. In addition, the Department will return at a later date to complete the continuation of this annual visit. An exit interview was conducted, and copy of this report was provided to the facility.