Routine inspection (multi-day)·March 11, 2025

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced continuous annual visit using the CARE inspection tool. LPA met with Virginia Garcia Administrator and explained the reason for the visit. On 2/24/25 LPA Flores conducted an annual visit and completed the following domains: Physical Plant/Environmental Safety : see report dated 2/24/25 for details. Food Service : sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Special diets are posted in the kitchen. Incidental Medical and Dental : medication was reviewed for 10 residents. During today visit LPA Flores complete the following domains: reviewed 10 resident and 10 staff files. Infection Control : Facility meets infection control procedures and the plan was reviewed. Staff have a TB test on file. Operational Requirements: LPA reviewed liability insurance which is current and meets all requirements. Staffing: Per LIC 500 there is sufficient staffing, there are 5 staff during the night shift and a front desk person. Staff have CPR/First Aid on file. Personnel Records/Staff Training: Ten staff files were reviewed with the required documentation. Initial and yearly 20 hours of training were observed for each staff. Administrator certificate was observed for Virginia Garcia #7006263740 exp. date: 10/14/26. Resident Rights/Information: Resident rights, PUB 475, Ombudsman poster were posted in common areas of the facility. Planned Activities: Activities calendar is posted in the activity area. An activity director is on duty and activities for persons with dementia were observed. (CONTINUED ON LIC 809C) Resident Records/Incident Reports: Ten resident files were reviewed. Appraisals and physician's reports were observed conducted within the last 12 months. Bed rails request were reviewed for each half/full bed rail observed. However, there were (3) residents observed with full bed rails and physician's request were observed but residents are not on hospice care. Disaster Preparedness: Emergency Disaster plan was reviewed and last reviewed on 3/1/24. Last emergency drill was conducted on 3/5/25. LPA observed an evacuation chair on top of each stairwell. Residents with Special Health Needs: Hospice plans were reviewed for pertaining residents. Staff have received training on Hospice care, Restricted Health conditions, Postural support and Dementia. A deficiency was noted today per Title 22 Regulations. Exit interview was conducted with Virginia Garcia and a copy of this report, LIC 809D, and appeal rights were provided.