Routine inspection·September 21, 2024

Licensing Program Analysts (LPAs) Erica Mosley and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:00 a.m. Upon arrival LPAs were greeted by the front desk receptionist and explained the reason for the visit. Marketing Director Jonathan McFall arrived at approx. 9:40 a.m. and The Executive Director (ED) Dion Gallarza arrived during the inspection. LPAs 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. The following was noted: At approx 9:47 am, the LPA's began the physical plant tour, the furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 09/03/2024. The LPAs observed required postings throughout the common space. The LPAs observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. The LPA’s observed an adequate supply of emergency food and water. The last fire inspection was completed on 10/30/2023 and was found to be in compliance with Fire Code Regulations at the time of inspection. Emergency disaster drills conducted quarterly as per regulation; the last one conducted on 08/12/2024. The LPAs inspected the kitchen/food service area at 9:52 a.m. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Continue on LIC809-C CONTINUE FROM LIC 809 From approx. 10:01 a.m. to 10:45 a.m. The LPAs observed seven (7) randomly selected resident bedrooms, of which two (2) were in memory care and five (5) in assisted living which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPAs observed a sufficient supply of towels and linens. 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 measured between 107.9 – 119.6 degrees Fahrenheit all within the required range. LPA’s reviewed Resident Records at approx. 10:40 a.m. Ten (10) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Ten (10) 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. During record review it was revealed that facility is approved for four (4) hospice residents however, the facility currently has five (5) residents on hospice. ED stated that their plan is to submit a hospice waiver increase. Infection Control / Emergency disaster planning: During today’s visit the LPA’S 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. CONTINUED FROM LIC 809-C LPA’s conducted a medication review on four (4) randomly selected residents at approx. 02:00 pm, The medications are centrally stored in the medication room located in the memory care unit. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. At approx. 2:24 pm medication review revealed that three (3) out of four (4) PRN medications for Resident #1 (R1) have been administered however a record of each dose has not been document on the resident’s record. Additionally at approximately 3:05 pm medication review reveal that Resident #2 (R2) medication ROSUVASTATIN 20 mg, 1 tablet per day, quantity 79, was started on 07/7/2024, has six (6) tablets left in the bottle. However there is no record of refusal which indicated there are four (4) extra pills. LPAs conducted interviews during the visit. LPAs obtained the following documents - Census, Staff schedule, and updated Limited Liability insurance. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of the report provided.