Routine inspection·January 23, 2024

On 01/23/24, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the Required Annual Inspection. LPA were greeted by receptionist, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Health Service Director (HSD) Annette Eggleston. Administrator (A1) Pamela Bradley arrived shortly. LPA conducted tour of facility with A1. Residents were observed seating in dining room and in memory care gathering room. Facility consists of Assisted Living (AL) and Memory Care (MC) Unit. There are 57 residents on the Assisted Living side and 40 residents in Memory Care unit. LPA toured a sample of resident bedrooms in Assisted Living and Memory Care. Facility has sufficient furnishings inside and outside for resident use. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards. Facility is equipped with pull stations and fire sprinklers throughout facility. Fire extinguisher was observed throughout the facility with a service date of: 10/26/23. LPA observed pull cords in resident bedrooms. Hot water temperature measured at 112.2 degrees in room 112, 111.6 degrees in room 105, 110.7 degrees in room 209, 111.6 degrees in room 24, and 110.8 degrees in room 21. LPA observed securely fastened grab bars and non-skid surfaces/mat in shower. Bathroom was observed operational. Medications were stored in a locked medication room in a medication cart. MARs and medications were reviewed. LPA observed exits in Memory Care to have a 30-second delay egress. Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and walk-in pantry. Walk-in refrigerator temperature was maintained at 38 degree F. and walk- in freezer was maintained at -12 degree F. The outside was toured and observed to be free from debris with outdoor seating available for residents. Exits tested in Memory Care and functioning properly and observed to have a 30-second delay egress. Facility resident and staff files reviewed during inspection and observed to have all the required documents. A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6. An exit interview was conducted. The following documents are requested and submitted to Fresno CCL by: 01/29/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current liability insurance, and Administrator certificate. A copy of this report and appeal rights was provided to Administrator.