Routine inspection·September 23, 2024

Licensing Program Analysts (LPAs) Erica Mosley and Sandra Urena conducted the required annual inspection. LPAs met with Kathleen Glass, Executive Director (ED) and explained the reason for visit was stated. Entrance interview conducted. LPA Urena and the ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. The fire extinguishers were fully charged and were last serviced on 07/31/2024. The facility’s Fire Drill Report dated 08/26/2024, records the date and time of the last test of the smoke detectors. The LPA observed required postings near the entrance way. The LPA observed the stairwells and they each had an emergency evacuation chair. The Activity Room/Library, and lounge areas were observed to be clean at the time of visit. At approximately 11: 24 a.m., the LPA observed residents playing Bingo in the library/activity room. BEDROOMS: The LPA randomly selected residents’ bedrooms. Most bedrooms are shared rooms. The bedrooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a sufficient supply of towels and linens. RESTROOMS: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water temperature in residents’ rooms ranged between 105.9 – 108.1 degrees Fahrenheit all within the required range. (Continue to LIC809c) (Continued from to LIC809) DINING/KITCHEN AREA: The dining room is located in a separate building (from the main residents’ building), adjacent to the patio area. The LPA observed a computer area for residents’ use, separated from the dining area. Weekly menus were observed at each table. In addition to the weekly menu, residents are given a choice of everyday food items they can order at La Carte. KITCHEN: Kitchen was observed to be inaccessible to residents in care. Knives and sharps were stored and inaccessible at the time of the visit. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable food. The kitchen has three (3) industrial walk-in refrigerators. Each refrigerator had a temperature thermometer which recorded the temperature at 38.0 degrees. In addition to the refrigerators, the kitchen has a walk-in freezer, which had the temperature recorded at below zero (0) degrees. Refrigerator and freezer temperatures are recorded in a log sheet three (3) times a day. The LPA found that the seven-day non-perishable food is not sufficient for the 84 currently admitted residents; furthermore, the emergency food is located in the basement of the Skill Nursing building (SNB). The food was found located on shelves that were blocked by additional kitchen equipment. OUTSIDE GROUNDS: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents’ use. No bodies of water were observed. The Weinberg building is currently not in use for resident care. LPA observed it to be empty at this time. It is currently used to store extra office supplies. Doors are locked and inaccessible to residents and it is monitored by guards in the evening. RESIDENT / PERSONNEL RECORDS: Resident Records and Personnel records were reviewed from approx. 11:20 am – 1:30 pm. LPA Mosley reviewed Resident Records at approx. 12:30 p.m. Eight (8) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. At approx. 1:30 pm Eight (8) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. All records were in order. (continue to LIC809C) (CONTINUED FROM LIC809C) Infection Control / Emergency disaster planning: During today’s visit LPA Mosley reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control are adequate. MEDICATION: LPA’s conducted a medication review on four (4) randomly selected residents at approx. 02:35 pm, The medications are centrally stored in the medication rooms located on both the 1 st and 2 nd floor. Medication for each resident is located on the floor they reside in. Both medication rooms were reviewed during the visit. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. No errors observed during review. LPAs conducted staff and resident interviews during the visit. During today's inspection, the facility is in compliance with Title 22 regulations. Decencies were. LPAs obtained the following documents - Resident roster, LIC 500, and copy of the Limited Liability insurance. Exit interview conducted. Copy of report provided.