Menifee Senior Living.

(Continued from Page 1) Shower logs and staff assignments records reflect that S1 did not provide care, including bathing assistance to R1 on the alleged dates. Documentation shows that R1 refused a scheduled shower on 9/23/2025 when assigned staff attempted to provide care. A review of records revealed no injuries or findings consistent with sexual abuse, and no evidence, witness statements, or independent information were obtained to corroborate the allegation. Interviews with facility staff and residents, including R1 and R1’s family members, there is insufficient evidence to support the allegation of sexual abuse. Regarding the allegation Staff handled resident in a rough manner. It was reported that Staff #2 (S2) on 9/7/2025 and 9/8/2025 S2 improperly tried to pull R1 out of bed, injuring R1’s shoulder. Facility records revealed that S2 did not work on 9/7/2025 and 9/8/2025, a review of medical records for R1 had a fall on 9/1/2025 at 0400 hours at the facility and was treated at the ER for Right foot fracture; left ankle sprain while attempting to ambulate to the bathroom. On 9/7/2025 R1 had an Emergency Room follow-up related to severe diarrhea. Interviews conducted with staff, residents, including R1 did not corroborate the allegation that staff handled R1 in a rough manner. Records further reflect that R1 experienced a significant decline in physical and cognitive condition during the relevant period, including multiple falls, decreased mobility and neurological complications requiring a higher level of care. Based on the inconsistencies in R1’s statements, lack of corroborating evidence, absence of physical findings, and the documented staff assignments, the allegations is deemed Unsubstantiated. The preponderance of evidence standard has not been met. Therefore, the above allegations are found to be Unsubstantiated. An exit interview was conducted with Rance Leth and a copy of this report along with LIC811- Confidential Names list was provided.

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility Business Manager with LPA identification and business card. Resident record review began- Five (5) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Employee records review began- Five (5) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current; expires 05/22/2026. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 110.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in their designated areas. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects inside kitchen. LPA verified there is a telephone working at this location. (Continued from LIC809, Page 2) 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 LIC809, Page 1) Food Service- Food supply meets the of one week supply of nonperishable and 2-day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation, and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors are tested and found to be operational annually by vendor Fire Alliance Inc. and last inspected on March 27-28, 2025 and a re-test on 04/21/2025. Fire extinguishers are tested or replaced annually and were last done so on 4/4/2024. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 06/24/2025. LPA observed a pool and spa surrounded by a 5 foot secured/locked iron-gate and maintenance is done weekly. Based on the information received during this visit today, there are no deficiency is being cited per Title 22, Division 6 of The California Code of Regulations. An exit interview was conducted were this report was reviewed with Vanessa and a copy will be emailed and a confirmation of receipt will be requested.

LPA reviewed three (3) unsigned Unusual Incident/Injury Reports (UI/IRs) regarding R1. The UI/IRs have a date on the bottom left corner stating “5/1/2023” and note the following. On 1/25/2023, R1 had a witnessed fall in the activity room. R1 was assessed, did not have any visible injuries, hit their head, or complain of pain. R1’s “R/P” and “PCP” were notified. The “Medical Treatment Necessary?” section is marked “No”. On 3/30/2023, R1 reported they felt dizzy which caused them to lose their balance and fall onto their buttocks. R1 was assessed for injuries and was observed with redness to their lower back. There were no other visible injuries or complaints of pain. R1’s “PCP” and family were notified. The “Medical Treatment Necessary?” section is marked “No”. On 4/7/2023, R1 reported on 4/5/2023 they fell in the restroom after losing their balance. R1 was assessed for injuries and reported mild left inner thigh pain. R1 denied hitting their head and staff did not see any visible injuries. R1’s “PCP” and family were notified. Family has since taken resident to urgent care for an x-ray and no fractures were found. The “Medical Treatment Necessary?” section is marked “No” and states “Resident was evaluated in urgent care”. A review of the facility’s Narrative Charting noted the following. On 1/25/2023 at approximately 7:30 p.m., R1 was sitting in a chair in the activity room and fell to their knees while attempting to stand up. R1 was able to get up by themselves and the fall was witnessed by staff. R1 did not hit their head, have any visible injuries, complain of pain, and the responsible person was notified. R1’s service plan will be reviewed/updated and “f/u with PCP”. On 3/30/2023 at approximately 7:00 a.m., R1 reported feeling dizzy earlier in the morning which caused them to lose their balance, hit their back on their dresser, and fall onto their buttocks. R1 denied hitting their head or having any pain. Staff assessed R1 for injuries and observed redness to R1’s lower back. Family was also notified. R1’s service plan will be reviewed/updated and “f/u with PCP”. On 4/7/2023 at approximately 7:00 a.m., R1 reported falling on 4/5/2023 at around 5:00 a.m., while attempting to get onto the toilet. R1 complained of mild pain to their inner left thigh. R1 denied hitting their head and staff did not see any visible injuries. Family has since taken resident to urgent care and no fractures were found. R1’s service plan will be reviewed/updated, “f/u with PCP”, and “PT/HH requested for recent falls”. Regarding the allegation, “Neglect/Lack of Supervision resulting in resident sustaining injuries” it was alleged R1 sustained fractures from experiencing unwitnessed falls in the facility. Staff 1 (S1) was interviewed and reported the following information. R1 had two (2) unwitnessed and one (1) witnessed fall while residing in the facility. During the unwitnessed falls, R1 was able to get up by themselves and did not notify staff until later during the day. R1 was assessed and did not have any visible injuries or change of condition and did not complain of severe pain, only soreness. 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 Staff checked on R1 every two (2) hours due to R1 being a fall risk. On 4/7/2023, R1 complained of pain and the facility gave R1’s family the option to transport R1 to urgent care or have staff send R1 out. R1’s family chose to transport R1 to urgent care. R1’s family reported R1 received x-rays, but nothing was found and R1 returned to the facility with no medication orders. R1 was referred to physical therapy due to their recent falls. R1 was reportedly taken to urgent care on 4/7/2023 after experiencing a fall in the facility. A review of R1’s medical records from Accelerated Urgent Care indicated R1 complained of bilateral hip pain and had been falling at approximately 4:00 a.m., while getting to the bathroom. The urgent care medical records stated, “There is no evidence for acute fracture. However, please note that in elderly patients a fracture may be occult and difficult to exclude with certainty by X-ray evaluation. To exclude an underlying subtle or occult fracture with certainty further evaluation with MRI is recommended.” A review of R1’s medical records from Loma Linda University Medical Center Murrieta noted on 4/21/2023, R1 was taken to the emergency room due to leg pain and having an unwitnessed fall on 4/5/2023. Medical records note R1 was taken to urgent care on 4/7/2023 and received back and hip X-rays and no abnormalities were noted. Medical records also note R1 received a CT scan of the left hip which showed fracture of superior and inferior pubic ramus as well as compression fracture of L5 vertebrae which appeared consistent with the cause of R1’s reported pain. Regarding the allegation, “Staff failed to seek timely medical attention after resident's fall” it was alleged the facility neglected to seek medical attention for R1 after the falls. An interview with two (2) additional staff was conducted who reported it is the facility’s protocol to activate emergency medical services when the facility learns a resident experienced an unwitnessed fall in the facility. However, LPA reviewed the facility’s program outline, and the “Medical Emergency” section notes the following. It is the facility’s policy to summon emergency medical services when a resident exhibits signs and systems of distress and/or emergency condition including a fall with deformity, severe pain or head injury. Non-emergency transport is only used when the resident needs urgent but non-emergency medical care, such as stitches, controlled bleeding, etc. The Resident Care Director or medication technician on duty is to contact the resident’s family/responsible person as quickly as possible, once the resident is safely under the care of the paramedics. 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 Additionally, the UI/IRs and Narrative Chartings documented R1 was assessed, did not complain of severe pain, head injury, or sustained a fall with deformity. One (1) of three (3) staff interviews conducted reported residents were checked on at least every hour during the nocturnal shift and additionally, as needed, if staff heard any unusual noises. One (1) of three (3) staff interviews conducted reported R1 constantly walked around in the facility and remained in their line of sight during day hours. R1 was interviewed and reported staff were always around. R1 was unable to recall if staff checked on them throughout the day. R1 reported they informed staff they were “fine” and requested staff leave them alone. LPA also made several unsuccessful attempts to conduct an interview with four (4) additional staff reportedly present during the alleged incident time-frames. The Department did not receive an additional care plan outlining a focus to prevent/reduce the risk of R1 falling. Regarding the allegation “Staff failed to notify authorized representative of resident’s fall” it was alleged the facility did not notify R1’s responsible person of two (2) of R1’s falls. The UI/IRs and Narrative Chartings documented R1’s “R/P”/family were notified after the falls. However, a witness interview was conducted with one (1) of R1’s healthcare POA agents who identified themselves as the main point of contact between R1’s family/POA agents and facility staff. The witness reported the facility informed them about the 1/25/2023 fall R1 experienced in the facility. The witness added R1 called them from their cellphone and informed them they experienced a second fall in the facility on approximately 3/30/2023. The witness does not know if R1 reported the second fall to facility staff. The witness reported they notified facility staff of R1’s second fall. The witness also reported R1’s family member visited R1 in the facility in April 2023 and informed facility staff they believed R1 required a medical evaluation due to having leg pain. The witness reported facility staff called them to notify them of the new information received. The witness reported on approximately 4/12/2023, R1 was removed from the facility and in the care of their family and taken to the hospital for further evaluation on 4/21/2023. During S1’s interview, they also confirmed R1 was removed from the facility on 4/12/2023 and in the care of their family. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this entire report and Confidential Names list (LIC 811) was reviewed and provided to Administrator Leth.

Allegation: “Staff do not ensure that resident is sufficiently fed while in care:” The complaint alleges that Resident #1 (R1) was not provided any meals on 11/16/2024. R1 stated on this date, they were experiencing leg pain and chose not to leave their room for meals. Interview with R1 revealed that there was a misunderstanding, and no complaint should have been filed. R1 indicated they are able to request meals in their room. However, at the time of the complaint, R1 did not request a meal, as R1 was not hungry. In another statement, R1 indicated they had slept through lunch and staff had brought her breakfast that day. Record review revealed that R1’s care assessment dated 10/27/2024, indicates meals – preparation only. According to staff interviewed, R1 prefers to stay in their room and requests meals be brought to their room. Occasionally R1 requests a staff escort to meals by pressing their pendant. Residents interviewed stated they receive all meals in the dining room daily or they can order with the staff and the meals can be delivered to their personal rooms. ED stated the dining room is open from 07:00AM to 06:00PM and residents can eat meals and/or snacks all day long. Care staff do have a checklist of their assigned residents and observe that their assigned residents attend meal service. If care staff do not see a resident at a meal, care staff will follow up with the resident to see if they would like to order a meal. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation "staff do not ensure that resident is sufficiently fed while in care" is deemed UNSUBSTANTIATED at this time. Allegation: “Staff do not respond timely to resident’s request for assistance:” The complaint alleges that on 11/16/2024 R1 pushed their pendant and no staff came to assist. During initial visit, R1’s pendant was tested and staff responded in less than 2 (two) minutes. Interview with staff revealed that there are typically 4 (four) care staff assigned to assist Assisted Living residents during the day. Facility policy states that staff respond to pendants within 15-20 minutes. Interview revealed there are times when the care staff is busy assisting other residents and may take longer to respond, but they still do their best to remain within the appropriate time frame. Care staff also carry walkie talkies and can request another staff to assist if the assigned caregiver is busy assisting another resident. Pendant response system is computerized, however, record retention is for a 30-day period, so LPA was unable to review response records for the date in question. Residents interviewed felt their needs are being met and staff are timely in responding to Report Continued on LIC 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 requests for assistance. R1 stated the complaint should never have been filed and most staff assist R1 timely whenever possible. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted with ED. A copy of today’s report was provided.

denied seeing mold inside their bedroom, and confirmed that there was no testing done in their bedroom for mold. Based on observations, interviews and records review the allegation of facility has mold is unsubstantiated. Facility roof is in disrepair It was alleged that on or around 01/25/24 there was a leak inside the roof in R1 and R2s bedroom. On 01/31/24 LPA conducted the initial 10 day visit to the facility and observed for right corner of the ceiling in the second bedroom in R1 and R2s unit to have been patched with a white temporary replacement tile/cover. Per interviews conducted with R1 and R2 there was a leak and it is in the process of being repaired. Per an interview with Maintenance Director Ryan Kolster the was a leak in the roof in the unit, that was discovered in December 2023, an HVAC Specialist came out and was able to drain the pipe. LPA conducted a records review (email) that revealed the Executive Director Rance Leth was aware of a leak, and had requested assistance with getting the leak remedied from corporate as, the issue was reoccurring. The leak was repaired on 1/22/24 as the drain was sealed the drain from the roof and a drip pan installed. Per an interview with Resident Services Director Rachelle Wheaton both R1 and R2 were offered to move to another unit but declined. Per an interview with R1 they did confirm that they declined to be moved as they like the view from their current unit. R2 reported it was the dripping sound that was the most bothersome. Based on observations, interviews and records review the allegation of facility roof is in disrepair is 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(s) occurred. An exit interview was conducted and a copy of this report and LIC 811-confidential names list was reviewed and provided to Executive Director Rance Leth.

(Continued from Page 1) bank statements and is taking any money from Resident. It was reported that Resident is responsible for their own finances. Information obtained from interview with Resident could not verify exact details of resident’s bank statements that were taken. Information obtained from an interview with an additional witness stated that staff did not steal Resident’s bank statements It was stated that Resident was in possession of all their banking information. It was further stated that there were no concerns regarding theft of Resident’s money or property. In regard to the allegation that Resident does not have access to a phone, it was reported that Resident is not allowed to use the phone. Information obtained from Administrator, indicated that Resident had access to a facility and mobile phone. It was advised that Resident was able to communicate with family when and as often as they desired. Interview with Administrator stated that two phones are available for any resident to use, and it is located at the front desk and the conference room for private calls. Information obtained from interview with Resident stated that a personal mobile phone can be used at any time. Information obtained from additional witnesses stated that Resident was able to speak with family and always had access to a phone. In regard to the allegation that facility overcharged resident for services, it was reported that Administrator charges Resident more than what was the admissions agreement indicates. Information obtained from interviews with Administrator stated that Resident’s Room Rate, Assisted Living Care Charge, laundry and cable services rate remained the same. It was advised that the Second Occupancy Rate increased to $50 on January 1, 2022. Information obtained from interview with Resident stated that charges were being billed and resident could not verify what the charges were. Information obtained from interview with an additional witness stated the facility was charging Resident as appropriate for the services. LPA conducted a review of resident’s admission agreement and assessments. All documents notifying of the increase were signed by resident. Based on staff interviews, resident interviews, witnesses’ interviews, facility records, resident files, the allegations staff stole resident’s bank statements, resident does not have access to a phone, and facility overcharged resident for services is Unfounded. (Continued on 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) meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Rance Leth and a copy of this report along with LIC811- Confidential Names list was provided.

Administrator denied that the facility had an outbreak due to incorrect handling of food prepared at the facility. Administrator indicated that they were advised of the concern of hair in food, but was unsure of the origin. An interview with Dining Director indicated that the only complaint they received was for the lack of food options and denied receiving a complaint regarding residents getting sick from the food. LPA conducted interviews with additional staff members who indicated that they were unaware of any foodborne illnesses at the facility between August 2023 and November 2023. It was also advised there were no concerns of issues and concerns regarding food preparation. Information obtained from interview with Resident 1 (R1) stated they found food on their plate and alleged it was due to staff not wearing a hairnet. It was also reported that R1 became ill after eating the food and the facility was advised of the concern. Interviews conducted with two (2) of the three (3) residents named in the complaint revealed that they became ill after eating the food served at the facility. The residents could not remember the exact dates that they became ill. Additional interviews with residents indicated that they had not experienced any issues with hair in their food and did not become sick from eating food prepared at the facility. A review of documentation revealed that Community Care Licensing (CCL) did not receive any food borne outbreak reports during the period from August 2023 to November 2023. Also, there were no reports or documentation of residents being medically evaluated outside of the facility. During a visit conducted on 03/27/2024, kitchen staff were observed wearing the proper kitchen gear, including hairnets and uniforms. It was documented on a previous visit conducted on 11/03/2023, the LPA did observe staff to be without hairnets. LPAs did not observe any health and safety concerns. Based on information obtained, the allegations that residents became ill after eating food served at the facility and that a resident found hair inside the food and on plates are unsubstantiated. Although the allegations may have occurred or may be valid, there is not enough evidence to prove that the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was discussed with and provided to the Administrator, Rance Leth.

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct a Case Management visit pertaining to a self-report made to RO on 11/25/2024 for theft of money from a resident and 12/3/2024 for theft of a ring for a resident. LPA Delgado met with Administrator Rance Leth to explain the reason for the visit, Administrator stated that Law enforcement was called and police reports were filed. Administrator stated that a search was conducted for Resident #1 (R1)'s missing money and a partial of it was recovered and the ring was recovered by the Resident #2 (R2)'s relative. LPA interviewed Administrator and one (1) staff. During the visit, LPA toured the facility, observed sufficient staff, did not find no immediate health and safety concern. There are no deficiencies being cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted and a copy of this report was reviewed with and provided to Facility representative.

On June 05, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator, Rance Leth. The facility file review was conducted in the Regional Office and additional forms were reviewed and requested on site. The facility is licensed for 220 ambulatory residents and has a waiver for 10 non-ambulatory residents. The facility currently operating at 200 residents of which 13 residents are on hospice, and about 30 residents in memory care. LPA Mixson toured the facility and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a three floored facility located at 28333 Valley Blvd, Sun City, CA. 92586. Physical Plant: The facility phone number is(951) 679-8811. The LPA observed a sampling of the residents’ living units, and they were equipped with required furniture as per Title 22. LPA Mixson inspected a sampling of the facility restrooms, and the hot water temperature tested within regulations. The restrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The LPA observed required postings such as "If you See Something, Say Something" the "Personal Rights" and the Ombudsman postings. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit. There was a pool and jacuzzi present which was fenced in meeting the height requirements. Medications : were locked and inaccessible to residents in care and located in the "Wellness Center." The overall facility is clean, the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit, and there were safety lights throughout the building. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Kitchen utensils were in sufficient supply and stored properly, and sharps are locked. Care & Supervision : Facility has sufficient staff on site at the time of this visit. Records Review: The LPA reviewed resident and staff files, conducted staff and resident interviews. Previous Community Care Licensing forms were reviewed. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit. An exit interview was conducted, and a copy of this report was given to the Administrator, Rance Leth.

On 7/26/2023, a complaint was received alleging staff does not ensure that the facility is maintained at a comfortable temperature for the residents. During the investigation interviews and record reviews were conducted. Interviews with residents revealed that it gets warm in the assisted living dining area but it is not unbearable because there are fans placed throughout the dining area. Residents interviewed also stated they are able to have their meals delivered to their rooms if it gets too warm. Interviews with staff revealed a new air conditioning system has been ordered for the assisted living dining area and in the meantime, fans are placed throughout the area. Staff also stated residents have the option of having meals delivered to their rooms. LPA toured the dining area and noticed three huge fans placed throughout the area. LPA observed the temperature to be at a comfortable level at the time. LPA viewed documents that revealed a purchase order for a new air conditioning system was placed for the dining area and expected to arrive in a few months. LPA also toured select residential units that were experiencing air conditioning issues. LPA observed portable air conditioners in place and units maintained a cool temperature. Based on observation, interview and record review this allegation is UNSUBSTANTIATED. On 7/26/2023, a complaint was received alleging staff does not ensure that facility dishes are properly cleaned and sanitized. LPA toured the kitchen area and inspected the dishwashing system. LPA observed a demonstration of dishes being cleaned and sanitized. LPA also observed clean dishes and clean silverware stored on shelves and on dining tables. Of the interviews conducted with residents, all residents indicated they were satisfied the facilities dishes, cups, silverware and that they all appeared to be clean. Of the interviews conducted with staff, all staff stated they have not observed or heard anyone complain about unclean or unsanitized dishes. Based on observation, interview and record review this allegation is UNSUBSTANTIATED; meaning that 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. An exit interview was conducted, and a copy of this report was provided.

Licensing Program Analyst (LPA) Cheryl Goodrich conducted an unannounced annual visit. LPA met the Administrator Rance Leth at the front desk and was granted entry. Advised Lance of the purpose of today’s visit, to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. The facility is approved for two hundred and twenty (220) ambulatory residents and has a waiver for 10 non-ambulatory residents. The facility currently has 173 residents of which 13 residents are on hospice, and 7 are in memory care. Physical Plant: front entrance, interior and surrounding exterior were clean and in good repair with no pathway obstruction; doorway alarms were in working order; residents' apartments consisted of bedroom with clean mattress and linen; and shower present with grab bars for assistance; there was sufficient lighting and mattress pads in all of the residents' bedrooms; fire alarm and smoke carbon monoxide detectors were in working order. There was a pool and jacuzzi present which was fenced in meeting the height requirements. Food Services : 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available to residents. Medication/Facility Records: Medications were observed to be labeled and in a locked place that is inaccessible to residents. All staff subject to a criminal record review obtained fingerprint clearance and/or an exemption. Staff responsible for direct care and supervision have current First Aid / CPR training. Licensee has completed a written admission agreement, current medical assessment and needs and service plan with each resident. Exceptions & waivers are in place and meet said terms. Licensee handles no resident cash resources. Administrator Certificate is current and will expire on 05/22/24. Summary : Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with Administrator Rance Leth and a copy of this report was printed Signature below confirms receipt of these rights.