Routine inspection·March 20, 2024

Licensing Program Analysts (LPA) Emily Peraldi and Licensing Program Manager (LPM) Kristin Heffernan arrived at the facility unannounced to conduct a required annual visit. At 9:50 a.m., the LPA was greeted by staff. At 9:58 a.m., the LPA met with the Executive Director (ED), Nancy Nelson and explained the reason for the visit. Between 10:57 a.m. and 12:46 p.m., the LPA and LPM along with the ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. The facility is a three (3) story building. Resident rooms are located throughout three floors. The neighborhood (memory care unit) is located on the first (1st) floor; Circle of Friends units and assisted living units are located on the second (2nd) and third (3rd) floor. Common spaces on the first floor include the reception area/lobby, bistro, dining room, and fitness room. The remaining floors each have their common spaces for activities, and all have appropriate furniture. All activity rooms and common spaces appeared clean and in good repair. A theater and salon are located on the third floor. Activity schedules are posted throughout the facility. There were no obstructions and/or tripping hazards throughout the facility. There are fire extinguishers throughout the facility, which were charged and last serviced 04/05/2023. Fire alarm/sprinkler system was tested on 02/19/2024. Kitchen: Dining is located on the first floor and was observed to be clean and sanitary. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food. Residents do not have access to the kitchen; dangerous items are stored inaccessible to residents. The menu was available for viewing and the facility offers daily specials and a standard selection at every meal. Snacks and beverages are available for residents. Continued on LIC 809C. Resident Units: The LPA, LPM and ED toured fourteen (14) randomly selected resident rooms throughout the community. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Restrooms: The LPA, LPM and ED observed restrooms in fourteen (14) resident units and common area restrooms. All restrooms were fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces in the bathing unit. The water temperature was tested throughout the visit including resident unit restrooms and common areas, and water measured between 107.4– 121.0 degrees Fahrenheit. The ED stated that the water temperature is going to be adjusted. Outside areas: There are multiple outdoor patios equipped with furniture for resident use as well as covered areas for resident use. The in-ground pool was appropriately fenced per regulation. Parking is available for residents and visitors. Starting at 1:59 p.m., the LPA and LPM conducted a review of medication, medication records, policy and procedures with medication technician. Audit for six (6) residents revealed that facility staff did not accurately record medications or had missing information on the Centrally Stored Medication and Destruction Record (CSMDR) for all six (6) residents’ medications reviewed. Three (3) out of six (6) residents’ medications reviewed, (Resident #1, Resident #2, Resident #3) did not have completed, or up-to-date CSMDR. The remaining three (3) out of six (6) residents’ medications reviewed, (Resident #4, Resident #5 and Resident #6) did not have CSMDR present during the medication review. The Director of Resident Care Services, Kelly Penrose, stated that facility staff will receive medication training and look for the missing CSMDR. Documentation: The LPA obtained a copy of the liability insurance, resident roster, and staff roster, Infection Control Plan, Emergency and Disaster Plan. Throughout the visit, LPA Peraldi interviewed four (4) residents. Due to time constraints, the LPA will return at a later date to complete the annual. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. A copy of the report and appeal rights were provided.