Routine inspection·February 6, 2024

On 2/6/24, at 10:30am, Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced annual required visit, with the use of the CARE Inspection Tool. LPA met with Loreen Hickman, Executive Director (ED) and explained the purpose of today’s visit. The facility is currently licensed to serve 47 ambulatory and non-ambulatory elderly residents. The facility is approved for 6 hospice residents. At 11am, LPA inspected the facility’s physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, parlor area, common TV area, activity area and outside of the facility to ensure compliance with Title 22 regulations. The facility is a two-story structure located in a residential neighborhood. There were no bodies of water on the premises. Entrance, exits and hallways were observed to be clear of obstructions. LPA inspected 4 resident apartments. LPA observed beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage for the resident's personal belongings. Bed linens, comforters, and bath towels were adequately stocked during the visit. Bathrooms were operational and adequately supplied including with grab bars and non-skid flooring. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were locked and not accessible to residents in care. The kitchen was inspected, and was observed to be clean and free of clutter. Facility maintains a sufficient 2-day perishable and 7-day non-perishable food. Room temperature was maintained in the facility at 74 degrees F in the hallway and 72 degree F in one resident apartments. Water temperature in two resident bathrooms were measured at 114 degrees F. Two fire extinguisher were inspected and both were serviced on 11/21/23. Smoke detectors and carbon monoxide were observed in each of the inspected apartments and found to be operable during this visit. {Con't to LIC809-C} {Con't from LIC809} Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and accessible to staff. The facility maintains for each resident Centrally Stored Medication, Destruction Record and PRN Log. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. During this inspection, LPA conducted an audit of facility files, 5 resident files, and 5 staff files for regulatory compliance. All staff noted on the facility staff roster have criminal background clearances and associated to this facility. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Staff files reviewed contained all required contents including health screening, TB results, current first aid, and initial and ongoing required trainings. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. LPA requested an updated copy of LIC 308, LIC 500, and liability insurance certificate. Per California Code of Regulations (Title 22, Division 6, Chapter 8), no deficiencies were observed during this visit. An exit interview was held with Loreen Hickman, and a copy of this report was provided to the facility.