Routine inspection·September 4, 2024

On 9/4/2024, 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’s conducted tour of facility with A1. Residents were observed, 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 freezer and refrigerator. Refrigerator temperature was observed maintained at 35 degrees F. and freezer was observed maintained at 0 degrees F. Ice machine was observed with yellow discoloring and half of the mechanism had black spots over the yellow discoloration. All chemicals were in locked storage. LPAs toured a sample of resident bedrooms, activity room, dining room and enclosed patio area. Residents' rooms were toured and observed with adequately furnished bed, dresser, and adequate lighting. LPAs observed securely fastened grab bars next to toilet and all tub/shower areas. 6 out of 6 residents rooms observed with non-skid shower strips. 6 out of 6 residents bathroom temperatures measured at 107.4, 106.3, 108.7, 109.3, 105.9, and 106.9 degrees. LPAs completed a medication audit. Medications were stored in a locked medication room in a medication cart. MARs and medications were reviewed. Review of Centrally Stored Medication Record revealed R1’s medication log was incomplete. Based on record review LPAs observed 1 out of 1 residents medication count was over the required amount. 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. An exit interview was conducted with Licensee. Report signed on-site; a copy of this report, 809D with appeal rights was provided.