Routine inspection·January 10, 2024

On 01/10/2024 at around 10:50 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Administrator Steve Cho. LPA explained the purpose of the visit and was accompanied by the Administrator inside and outside the facility during this inspection. This facility is licensed to serve 120 non-ambulatory residents, of which 35 may be bedridden. This facility is approved for 10 hospice residents. A total of 89 residents currently resides in this facility, of which 12 are bedridden. The facility has a balance of $1,982 in Annual Licensing Fees due on 01/29/2024. The facility is a four-story building located on a main street. The basement/first floor consists of a parking garage. The second floor consists of the medicine room, industrial kitchen, front desk, dining room, several community rooms, patio area with shaded seating, and resident rooms for assisted living. The third floor consists of resident rooms for assisted living, and community rooms. The fourth floor consists of the memory care unit, the bedridden unit, and resident bedrooms. There are no security bars or weapons on the premises. LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinets. LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last fire drill was conducted on 12/12/2023. First aid kit is fully stocked with manual. Last annual fire inspection was conducted on 09/01/2023. There are several fire extinguishers around the facility, and they were last services on 09/01/2023. LPA did not observe an evacuation chair at each stairwell. There is a landline resident telephone on the front desk. Several resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb. 5 staff records were reviewed, 5 out of 5 staff records had First Aid Certificates, Criminal Record Clearances, Job Applications, Facility Trainings/Drills, and signed Employee Rights. 1 out 5 staff record did not a Health Screening report and Tuberculosis Test. 5 resident records were reviewed and, 5 out of 5 resident records had Admission Agreements, Consent Forms, Emergency Information, Tuberculosis Test, Centrally Stored Medication Destruction Record, and Personal Rights. 3 out 5 resident records did not have an updated Medical Assessment and Appraisal & Needs Service Plan. Deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds. A violation regarding evacuation chair, staff records, and resident records. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator.