Routine inspection·December 16, 2024

Licensing Program Analyst (LPA) Rachel Bruce arrived unannounced to conduct the Annual inspection. LPA met with Assistant Administrator Joanna Tilghman (AA) and explained the purpose of the visit. Facility was toured with AA, including main house, garage and storage areas, outside recreational area, and six resident building units. Resident rooms contained required furnishings and lighting. LPA observed required items in bathrooms. Resident hygiene supplies were properly stored and available as well as extra linen, and overflow of necessary items. In the main house the bathroom water temperature was 108 degrees F. In building 105 the bathroom water temp 108.9 degrees F. In building 106 the bathroom was in use no test was conducted. In building 104 the bathroom water temperature was 106.3 degrees F. In building 103 the bathroom water temperature was 105.4 degrees F. In building 102 the bathroom water temperature measured 104.7 degrees F and in building 101 the bathroom water temperature was 100 degree F. The kitchen was toured and observed to be in good repair with necessary items and appliances. Sharps/knives are stored in drawer, but doors leading to kitchen are kept locked. LPA observed required food supply and paper products. There is a dry storage area kept locked outside the general kitchen area. Canned foods are ordered and delivered on a regular basis however the cans expiration date is listed on the delivery box and not the individual cans. LPA was unable to determine the freshness of food in storage. There are 2 refrigerators in the storage/garage area that hold overflow. Medications are centrally stored and locked. Medical review of distribution records and pill count was completed by LPA. For 11 residents LPA found errors in the distribution. There were no initials only an "X" so there was no way of knowing who gave the medication and secondly there were missing doses and no indication of why, i.e. resident was in hospital, resident refused etc. The AA indicated in those instances it appears to be staff error. First aid supplies located in Main House and found to contain required items. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. The backyard is clean and provides ample space for residents to walk or recreate. Seating is available as well. Fire Extinguishers are located throughout the facility and were serviced by Valley Fire on 6/7/2024. Per Facility record there are 30 smoke detectors which are checked and batteries replaced as needed by maintenance. Records of smoke alarm checks can be found in maintenance binder. Last documented inspection was June 3, 2024. LPA reviewed Jorgensen & Co. Fire Alarm System Service Report dated September 13, 2024. On that date sprinklers were inspected by the Fire Department and Jorgensen jointly. The report indicates the facility failed the inspection due to an issue with 2 automatic sprinkler heads located outside. The necessary repair/replacement was completed and a re-inspection completed on 12/10/24. AA will forward successful report to CCL when received. Administration certifications are current. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D. An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and will be provided to AA. At the time the inspection was over, AA was not available to sign so Bonnie Martin, House Manager was given permission to sign. LPA is requesting the following documents be submitted to the Fresno CCL office by 1/12/2025 : Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), and Register of Facility Clients/Residents for (LIC9020A).