Routine inspection·May 18, 2023

Licensing Program Analysts (LPAs) Galarza and Joe Katrdzhyan conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Business Office Manager Christ ina Schoech and Wellness Director Denise Bartley. There are currently 46 elderly residents 60 years and older residing in the facility. Two (2) residents are receiving hospice care. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. The facility does not have a Dementia Waiver in place. A Hospice Waiver for 8 is approved. A fire clearance for 85 non-ambulatory residents; of which 7 may be bedridden is in place. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. No Surety bond is in place. Facility does not handle resident monies. Physical Plant/Environment Safety: The facility does not have Dementia residents. A hospice waiver for 8 residents is in place. Facility is a 2-story building consisting of 73 resident rooms, 2 activity rooms, beauty salon, dining room, laundry room, and a courtyard patio area. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. On 2/8/2023, LA County FIre Department conducted an inspection to correct the violations identified in the Fire Department report. The sprinkler system, alarms, fire connections, and kitchen hood system were inspected. The facility has f ully charged fire extinguishers. Water temperature readings did not measured within the required 105 - 120 degrees Fahrenheit, and kitchen hot water faucets measured below 125 DF . Rooms 229 (120.3 DF), 235 (120.9 DF), 243 (122.3 DF), 251 (121.8 DF), 252 (122.1 DF), 257 (121.2 DF) Room 117 entrance wall was in disrepair. Staffing: A total of 33 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator on record is not current. A new Administrator began working at the facility on May 15, 2023. Documents are pending. Staff have criminal background clearance and training. Seven (7) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training was observed. One (1) out of seven (7) staff did not have current 1st Aid/CPR training. Resident Records/Incident Reports: A total of ten (10) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records. RCFE complaint poster and Personal rights were observed posted. The Incident report binder was reviewed. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted by the game room. The facility has a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Sanitation practices and kitchen cleanliness was observed. Incident Medical and Dental: Seven (7) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. See next page Residents with Special Health Needs: Eleven (11) residents are receiving home health services. Two (2) resident receive hospice care. Postural support physician orders are on file. No half bed rails for mobility assistance were observed in resident rooms. Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Denise Bartley. A copy of the report and appeal rights were issued.