Routine inspection·February 20, 2024

On 2/20/2024 at 1:00PM, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson, arrived unannounced to continue the 1-Year Annual Required inspection visit. LPAs met with Executive Director (ED), Jeffrey Freeth, and explained the purpose of the visit. Administrator certificate #6062809740 expires 7/10/2024. The facility’s fire clearance was 104 non-ambulatory, 40 ambulatory and 6 bedridden residents. Facility has hospice waiver for 12 residents. LPAs toured the facility with Administrator including but not limited to apartments, bathrooms, kitchen, common area, med tech room, and outside. LPAs toured apartments #166, #260, #317, and #319. All outdoor and indoor passageways are kept free of obstruction. LPAs did not observe any bodies of water. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 113.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non slip shower mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/12/2024. First aid kit was observed to be complete. Fire drill was last conducted on 02/19/2024. Continued on LIC809C. Continued from LIC809. LPAs reviewed ten (10) staff records, ten (10) resident record and vehicle maintenance log. LPA requested the following documents to be submitted to CCLD by 02/27/2024. LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance LPA observed the following deficiencies: At 3:35pm, LPAs observed during record review majority of staff were not first aid or CPR certified. At 3:40pm, LPAs observed during record review several staff did not have a health screening or TB test on record. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy the appeal rights and the report provided.