Routine inspection·September 15, 2023

Licensing Program Analysts (LPA) Brian Balisi  arrived at the facility unannounced to conduct a required annual visit at 11:30am. Upon arrival LPA met with Administrator Anait Asatrian , and explained the reason for the visit.  The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The LPA began the inspection in the kitchen/food service area. The kitchen appeared clean and the appliances and fixtures functional during the time of visit.  LPA observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects are stored in a locked drawer to the left of the sink. LPA did not observe cleaning supplies stored in this area.  Medication is stored in a locked cabinet across from the fridge. LPAs inspected the common areas throughout the facility inside and out.  All areas have been appropriately furnished.  The common areas were observed to be  properly furnished and relatively clean during the visit.  LPA observed appropriate signage regarding infection control posted throughout the facility.  LPA observed sanitizer readily available in areas with high touch surfaces. Dining room and living room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed throughout the facility,  fully charged and were scheduled for service at the end of this month. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. At approximately 11:50am  LPAs inspected all four (4) resident bedrooms. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed all bathrooms  were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The laundry area is located at the entrance of the main hallway. Cleaning supplies and detergent were observed stored inaccessible to residents in care. There is a closet used for facility supplies located in room #4. LPA observed closet locked and inaccessible during the visit. LPA observed extra non-perishable foods, PPE and incontinent supplies stored in the closet. Surrounding Grounds (Outdoors): There are two (2) shaded areas located in the rear of the facility with proper furniture for outdoor use.  There are no bodies of water on the premises. At the rear of the facility is a small space to store trash bins. LPA did not observe any obstructions blocking the emergency exit route. Records review began at 1p.m.,  three (3) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. At 1:30pm,  three (3) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time. At approximately 1:30pm, Administrator stated they have not conducted an emergency disaster drill in 2023. Medications review began at approximately 2:30pm The medications are centrally stored in a cabinet in the living room area. LPA observed it to be  inaccessible to residents in care. Medications are properly documented on the centrally stored medications and destruction record. Infection Control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate each resident bedroom as a single isolation rooms if the facility has a confirmed case of a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate at this time. Continued from 809-C Staff living area is located in the front of the home. LPA observed it to be inaccessible to residents in care. LPA observed it to be empty at the time of the visit. Between 11:30am - 12:30pm the LPA interviewed two (2) staff members and three (3) residents. LPAs obtained the following documents - Census, Staff schedule, Emergency Disaster plan and updated Limited Liability insurance. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.