Routine inspection·October 11, 2021

Licensing Program Analyst(s) (LPA) Mary Flores and Jewel Baptiste conducted an unannounced annual visit using the inspection tool. LPAs met with Rocio Gonzalez Wellness Director and explain the reason for the visit. Pasadena Department of Public Health Nurses Whitney Frame and Kevin Grellman join LPAs at 10:30am. The facility is licensed to serve 206 residents over the age of 60 years old of which 171 may be non-ambulatory, 35 bedridden, and a hospice waiver for 20 hospice residents. There are currently 12 residents on hospice. Facility cares for dementia residents and has delayed egress on exit doors. There is a water feature in the courtyard. The water feature has a fence around the entire perimeter. LPAs conducted a tour of the facility with Rocio Gonzalez and observed the following regarding Physical Plant and Food Service Domain: Resident rooms were randomly chosen #209, 214, 217, 220, 223, 232, 239, 256, 122, 125, 130, 134, 136, LPAs observed all required furniture, bedding items, sufficient lighting, in each bedroom and resident's bathrooms were observed with skid mats/skid strips, grab bars, and water was tested between 98.5 and 114.5 degrees F which is not within the required range of 105 - 120 degrees F. The large commercial kitchen was toured, sufficient food was observed, refrigerators' temperature was observed at 40 degrees and freezer's temperature was observed at 0 degrees. LPAs tested emergency call light in room #217, 239, 134 caregivers did not responded to call, LPAs and wellness director waited for 5 minutes. Infection Control Domain: LPAs observed updated COVID signs around the facility, screening questionnaire was updated, in service training were provided to staff regarding proper hand washing, face covering, social distancing, proper disinfecting, donning and doffing. Staff had individual hand sanitizers. It was recommended that all disinfected bottles are label and dated, and that additional closed lid trash cans are provided in the restrooms. As well as further in service training for staff regarding COVID 19 recommendations and guidelines. Deficiencies were given during this visit under Title 22. Exit interview was conducted with Virginia Garcia administrator and a copy of this report, LIC 809D, and appeal rights were provided.