Routine inspection·December 6, 2023

At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with Administrator Nadia Roop. At approximately 8:30AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerator and freezer were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Facility has fire sprinklers throughout. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure. At approximately 9:15AM, LPA reviewed 5 of 7 resident records. All records contained the required documentation. Medication records are thorough and contained physician's orders for each resident. One of 7 residents are receiving Hospice services and the Hospice care plan was up to date. At approximately 9:45AM, LPA reviewed 5 staff records. Five of 5 records did not contain documentation of completed training as required. Evidence of current first aid and CPR training were current. At approximately 10:50AM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has the required evacuation stair chair in place. Facility has supplies enough to operate for more than 72 hours in an emergency. Continued on LIC809-C... Facility does not have documentation of completed emergency drills. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Evidence of Liability Insurance Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with the Administrator and Appeal rights were given.