Inspector’s narrative
What the inspector wrote
Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 8:55AM for a required one-year visit. The LPA met with Resident Care Services Director (RCSD) Cortney Barber and explained the reason for the visit. Entrance interview conducted. Executive Director (ED) Abigail Traxler arrived at 10:33AM.
At 9:45AM, the LPA and RCSD 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 facility is a five-story building. The following was observed:
RESIDENT ROOMS:
The LPA observed randomly selected rooms on the first, second, third, and fourth floors and no immediate health or safety hazards were observed. Restrooms were clean, with properly installed grab-bars in resident restrooms and non-skid strips in shower tubs. Appropriate furniture was also observed in the units. Water temperature was tested throughout the units and measured between 104.5 degrees F and 133.5 degrees F, which is not within the required range of 105 degrees F and 120 degrees F. Additionally, the LPA observed two (2) out of six (6) resident restroom sinks to be clogged and slow to drain during the visit. One (1) resident stated their sink had been clogged “for quite some time” and submitted a work order in addition to notifying staff. RCSD and ED immediately notified the building engineer to repair the sinks’ drainage.
Report Continued on LIC 809-C
COMMON AREAS:
The facility has five (5) total floors: basement/parking garage, first floor, second floor, third floor, and fourth floor. The basement provided general parking, contained emergency food and water, and general storage as well as extra facility supplies/emergency supplies. On the first floor, there was the concierge desk, the great room, common restrooms, bistro, bistro patio, staff lockers, dining room, courtyard, kitchen, and memory care unit. The memory care unit contained resident units, common restrooms, a courtyard, laundry room, and office. On the second floor, there was a wellness center, resident units, town hall room, activity room, balcony, and common restrooms. On the third floor, there was a beauty salon, resident units, discovery room, gym, card room, laundry room, and common restrooms. On the fourth floor, there was a laundry room, resident units, terrace rooftop, office, and common restrooms. LPA Huynh observed common areas to be clean, clear of obstructions/hazards, and furniture was in good condition with patios/courtyards providing shade for residents. Required postings were found in the hallway on the first floor. There were no bodies of water observed during today’s visit. There were fire extinguishers throughout the facility, which were serviced on 09/11/2024.
KITCHEN:
The main kitchen is located on the first floor, attached to the main dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. Facility uses Sysco Foods for food deliveries which occurs every Wednesday and produce deliveries occurs every Monday, Thursday, and Saturday. There was a sufficient supply of perishable and non-perishable food. The LPA observed the walk-in refrigerator and freezer; food appeared to be of good quality and labeled with expiration dates. Kitchen sinks had signage of tap water delivering above 125 degrees F.
MEDICATION:
Medication review began at 11:00AM. The LPA reviewed medications for five (5) residents. Medications are maintained locked inaccessible to residents in the Wellness Center located on the second floor. Resident medications reviewed were documented and stored in compliance with regulation at this time.
Report Continued on LIC 809-C
RECORDS:
Resident records were reviewed at 11:38AM. LPA Huynh reviewed five (5) files for, but not limited to: admissions agreements, medical assessment, appraisals, and consent forms. Resident records reviewed were in order at this time. The LPA reviewed six (6) personnel records for, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification, and appropriate training. Staff files reviewed were in compliance with regulation at this time.
INFECTION CONTROL/EMERGENCY DISASTER:
The
LPA reviewed the facility's Infection Control Plan and Emergency Disaster Plan. LPA noted that the facility is in compliance with regulation with both plans reviewed annually. The facility conducts emergency disaster drills as required, with the last drill documented on 05/29/2025. Fire alarm system is tested annually with the last inspection on 05/15/2025 by Absolute Fire Inspection, Inc. with a follow up inspection to be determined.
Four (4) residents and six (6) staff were interviewed. No complaints noted.
LPA Huynh obtained the following documents: LIC 500 Personnel Report, Resident Census/Roster, Emergency Disaster Plan, Infection Control Plan, and Dementia Plan of Operation.
Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (Refer to LIC 809-D).
Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.
