Routine inspection (multi-day)·November 7, 2023

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to finish the annual inspection. LPA met with Director of Resident Engagement, Cathy Huo, and explained the reason for the visit. During the visit today, LPA completed the remainder of the inspection and the following were reviewed: Staffing : The facility has sufficient staffing to meet the needs of the residents. There are awake staff providing night supervision. Personnel Records-Training : LPA reviewed 4 Staff files. The administrator's certificate expires on 1/21/25. Staff have fingerprint clearance and associated to the facility. 2 out of 4 staff files are missing the health screening form. Staff have appropriate dementia care training. Resident Records-Incident Reports: LPA reviewed 5 resident files. The files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, and care plan. The physician's report for 3 residents (Residents #1, #2, and #4) are not current. Resident Rights-Information : Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff. Residents with SHN : Facility accepts and retain residents with dementia. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence. No smoking-Oxygen in use signs are posted where appropriate. Deficiencies are issued on the LIC809D. An exit interview was held with Cathy Huo. A copy of this report along with appeal rights are given to staff.