Routine inspection·September 26, 2024

Licensing Program Analyst (LPA) Alicia Delmundo conducted an unannounced annual required inspection. LPA met with Associate Executive Director (AED) Rosana Frias, and informed the reason for visit. Facility is a seven story building, the 2nd, 3rd, 4th and 5th floors of which houses assisted living residents. Facility has LIC9282 Infection Control Plan, and updated copy provided to LPA on this same day. LPA inspected the facility inside and out with AED. LPA inspected the common areas, activity rooms, kitchen, dining rooms, Life Enhancement area, lounge/bistro. theater, fitness center/room, courtyard and back patio. Salon, housekeeping supplies room, massage/therapy rooms on the first floor were inspected. Electrical and housekeeping supplies rooms, laundry rooms on other floors were checked. Food supplies were observed good for 7 days of non perishables and 2 days of perishables. Freezers and refrigerators temperatures are checked by kitchen staff and records kept and observed within Regulations range. LPA randomly selected 10 residents rooms for inspection - 4 rooms on 2nd floor, 2 rooms on the 3rd floor, and 3 rooms each on 4th and 5th floors. Facility has carbon monoxide and smoke detectors that are in operating condition. Hot water temperature in one of the residents' bathroom on the 3rd floor was checked and measured at 114.6 degrees Fahrenheit. Fire extinguisher in the kitchen was observed fully charge with tag showed serviced April 4, 2024. Facility has evacuation chairs on stairwells. Facility conducts disaster drills and records showed last conducted August 26, 2024. LPA reviewed 5 staff and 6 residents files, and interviewed 4 residents. ....continued on 809C LPA observed the following: -at 1:44 pm, razor, hair developer, perming agent, waving lotion, anti fungal wash and screw driver in unlocked drawers in unlocked salon. -at 2:09 pm, Peritoneal cleanser in the resident's room in Memory Care Unit. -at 2:37 pm, stained/soiled carpet flooring in resident's room on the 3rd floor. -at 2:40 pm, resident (R3) has medications in the bathroom. R3's LIC602A indicated dementia. LPA verified, and per Wellness Director, R3 is on facility's Medication Program. -at 2:57 pm, cleaning supplies in unlocked housekeeping room on the 5th floor. -at 3:05 pm, stained/soiled carpet flooring in resident's room on the 5th floor. -at 4:45 pm, staff (S3) does not have the 20 total hours of required training for 2023. -at 5:20, staff (S1 and S5) has not completed the required 40 hours of training. S5 has not completed the required total initial hours of medication training. -at 6:00 pm, residents (R2 and R4) has postural support (halo; half bed rails) but no doctor's orders on file. The following updated/current documents to be submitted by October 10, 2024: 1. LIC308 Designation of Facility Responsibility 2, LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation of section 87309(a) within 12 month period. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Deficiencies and plan and proof of corrections were discuss with AED. Due to time constraint, LPA will come back to continue inspection. Exit interview conducted. Appeal Rights, LIC421FC Civil Penaly Assessment, LIC9098 Proof of Correction form and copy of this report provided.