Routine inspection·October 14, 2024

Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Director of Wellness Sev Tienda and explained the purpose for todays visit. The facility is licensed to serve a capacity of two hundred (250) residents ages 60 and above, with a maximum of (25) Non-Ambulatory in the Bradbury Building. There is an approved Hospice Waiver on file for six (4) residents. There is an approved Dementia Care plan is in place. This is a Continuing Care Retirement Community (CCRC) which includes separate buildings throughout the premises ; Independent Living, Assisted Living and Skilled Nursing. The Assisted Living residents reside on the second floor of the Bradbury Oaks building and o ther residents are at the Independent Living care section. The w ander guard system is used in the Bradbury Oaks building (second floor) for residents diagnosed with dementia or wand ering behaviors, this was tested during visit and was in working order. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility has sufficient PPE supplies and there is an Infection Control Plan. Operational Requirements: The facility has an approved fire clearance and facility maintains the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, multiple residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facilities residents private bathrooms and measured within the required range of 105-120 degrees. There are multiple shaded patio/garden areas for residents. (continued on 809-C) Staffing : There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training : Staff have criminal record clearance, current First-Aid/CPR/AED, trainings are documented in personnel files. LPA reviewed 10 staff files with no issues observed. Executive Director / Administrator Andrew Smith certificate expires on 2/11/2025. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 10 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted throughout common areas: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There is sufficient space both indoor and outdoor for activities. Food Service: The kitchens were observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables, along with the emergency food supply. Incidental Medical & Dental: Medication is properly labeled and are centrally stored and are in their original containers. LPA toured Medication Room within the Bradbury Building with no issues observed. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 9/11/24 in the assisted living (Bradbury Building) and on 9/25/24 in the Independent Living. Residents with Special Health Needs: There are currently no residents in the facility on Hospice, however, staff are properly trained to assist with resident who have special health needs. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays visit. Exit interview held and a copy of the report was provided to Director of Wellness Sev Tienda