Routine inspection (multi-day)·April 16, 2024

Licensing Program Analysts (LPA) Erik Zaragoza conducted a subsequent unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools in order to complete the annual inspection. LPA explained the purpose of the visit Diana Medina, administrator for the facility, and was granted entrance. There are one-hundred and sixty-two (162) residents currently living in the facility. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control practices and Personal Protective Equipment (PPEs) were observed. · Infection control plan is on file. Physical Plant/Environment Safety: · The facility consists of four separate buildings all located on a campus. It is licensed for a capacity of one-hundred (100) ambulatory and eighty five (85) non-ambulatory residents, with a hospice waiver approved for eight (8) residents. LPA toured building #1 which has a total of forty-five (45) resident bedrooms, building #2 which has sixty-two (62) bedrooms, Building #3 which has a total of sixty-five (65) bedrooms, and Building #4 which has thirty-three (33) bedrooms and also serves as the facility’s memory care unit. Buildings 1-3 have rooms that contain kitchenettes, laundry rooms, and common areas for resident use. The facility has resident activity areas available in each building. The main building which is building #1 contains two activity areas, a gym, dining room, main dining room and a commercial kitchen. Building #4 contains an activity room for residents. The facility has a signal system that properly works from residents living units and bathrooms. The facility was observed to be in good repair. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. A water fountain on the facility premises is properly fenced and in compliance with state and local building codes. The facility has multiple fully charged fire extinguishers located throughout all four (4) building of the campus. There were no sharp objects that were left accessible to residents. · Water temperature readings in four (4) out of twenty-eight (28) resident rooms reviewed fell below the required range of 105 - 120 degrees Fahrenheit. Operational Requirements: · The Program Design was reviewed. · Fire clearance was approved by LA County Fire Department for a capacity of one-hundred (100) ambulatory and eighty five (85) non-ambulatory residents, with a hospice waiver approved for eight (8) residents. · Care and supervision to meet the clients’ needs was observed. Staffing: · A total of one-hundred and sixty-seven (167) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Eight (8) staff files were reviewed for criminal background clearance and training. · Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training. Resident Rights/Information: · Physician orders were reviewed for eight (8) resident files. · Medications were also reviewed for eight (8) residents. Resident Records/Incident Reports: · Eight (8) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. · Staff training was on file. Disaster Preparedness: · Emergency and Disaster Plan was publicly posted and found within the facility. · An emergency and disaster drill was last conducted on 3/19/2024. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs: · The facility has a non-ambulatory fire clearance for each room that will be used to accommodate residents with a dementia diagnosis. · Staff that provide direct care to residents with dementia receive training related to dementia care. · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit are documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided.