Routine inspection·September 16, 2024

Licensing Program Analyst (LPA) Alberto Lopez 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 Director of Health services Arienne Ghammangne and Administrator Rochelle Carpio arrived a short time later and assisted with the visit. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan. Operational Requirements: A current Plan of Operation was reviewed. The facility serves residents 60 years and older, and a Hospice Waiver for ten (10) resident is approved. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. A surety bond is not applicable. Facility does not handle resident's money. Physical Plant/Environment Safety: The facility consists of a 2 story building with resident rooms on both floors. The main floor has a lobby, library, bistro area, dining room, kitchen, administrative offices, and spacious outdoor patio. The 2nd floor consists mainly of resident rooms and a dining room. There are no swimming pool or bodies of water on the premises. There are no firearms or weapons stored at the facility. LPA selected random rooms - (rooms #157, #159, #161, #204, #203, and #223) to measure the hot water temperature. The temperatures measured between 93.7-122 degrees F which is not the required range of 105-120 degrees F. The supply of dishes/cups is adequate. During today's visit. The facility smoke detectors are hard wired. Carbon monoxide detectors were observed throughout the facility. The fire extinguishers were fully charged and in compliance. The grounds of the facility are well landscaped with a ramp that leads to the entrance. A shaded area with chairs is provided in the patio area. The facility is equipped with a centralized sprinkler system. The north fire door was tested and does not operate. LPA asked facility to report to Fire Department and CCL and facility agreed. Staffing: There appears to be always sufficient staffing in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records/Staff Training: Staff have criminal record clearance, current First-Aid training along with training in medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no deficiencies observed. Administrator Rochelle Carpio certificate expires on 01/21/2025 Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman near the entrance. A total of five (5) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. (continued) Food Service: Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Incident Medical and Dental: Five (5) centrally stored resident medications were reviewed. Medication is given according to doctor’s orders. Medical and dental transportation is provided by family, transportation services, or staff. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. LIC610 needs to be updated when all staff are trained on shut of utilities. Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. Facility admits residents with dementia and staff have all required training documented within personnel files. Per California Code of Regulations, Title 22, deficiencies were cited. Technical Advisory provided. Exit interview was conducted with staff. A copy of the report and appeal rights were issued. Civil penalties issued for repeat violation.