Routine inspection·August 13, 2024

On 8/13/2024, Licensing Program Analysts (LPAs) J. Leffall and K.Kaur arrived at the facility unannounced to conduct the Required Annual Inspection. LPAs were greeted by receptionist, stated the purpose of the visit and met with Administrator (A1) Linda Pope. LPA conducted tour of facility with A1. Residents were observed seating in lobby, dining area and activity room. The facility was observed to be at a comfortable temperature, clean, in good repair with no passageway obstructions or fire hazards. Fire extinguisher was observed with a service date of: 11/21/2023. Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer and walk-in refrigerator. Refrigerator temperature was observed maintained at 34-degree F. and freezer was observed maintained at -10-degree F. At 9:43 AM LPAs observed Trash room unlocked with Carpet Shampoo. LPAs toured on the 1 st floor: a sample of resident bedrooms, activity room, club room, dining room and fitness center. Tour continued to 2 nd floor. At 10:12AM LPAs observed Clorox bleach and Shout cleaner unlocked in residents’ laundry. Second floor observed LPA’s 7 Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. LPAs observed securely fastened grab bars next to toilet and all tub/shower areas. 7 out of 7 residents rooms observed without non-skid mats. 6 out of 7 residents bathroom temperatures measured above 120 F. LPAs completed a medication audit. Medications were stored in a locked medication room in a medication cart. MARs and medications were reviewed. LPAs observed R1’s medication was not logged in Centrally Stored Medication and Destruction Record (CSMDR). LPAs observed CSMDR was incomplete/ missing information. Based on record review LPAs observed 3 out of 3 residents that had missed medication. A sample of staff files were reviewed to have the required documents. A sample of resident’s files were reviewed to have all the required documents. Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22,Division 6. LPA is requesting the following documents be submitted to the Fresno CCL office by 8/31/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020. An exit interview was conducted with Licensee. Report signed on-site; a copy of this report, 809D with appeal rights was provided.