Routine inspection·July 12, 2023

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. The LPA met with Executive Director Elizabeth Spencer and informed them of the reason for the visit. At 9:55 a.m., the LPA and the Executive Director 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. Common Areas: The facility is a three-story building. There are resident rooms on all three floors, units are designated for assisted living residents on all three floors. In addition, there are additional resident units in six (6) stand-alone buildings. Common spaces on the first floor include the theater, salon, secured pool, and spa. The second floor includes the reception area/lobby, library, activity rooms, fitness room, and physical therapy room. The third floor includes the kitchen/dining services, and activity rooms. There were no obstructions and/or tripping hazards throughout the facility. There are fire extinguishers throughout the facility, which were charged and last serviced 8/2022. Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging residents in group activities. All activity rooms and common spaces appeared clean and in good repair. Kitchen: Dining is located on the third floor and was observed to be clean and sanitary. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food. The menu was posted, and the facility offers daily specials and a standard selection at every meal. Snacks and beverages are available for residents in the Bistro area on the 2nd floor. Resident Units: The LPA and Executive Director toured thirteen (13) randomly selected resident units throughout the community. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Smoke detectors observed in resident units were operational at the time of the visit. Restrooms: The LPA and Executive Director observed restrooms in thirteen (13) resident units. 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. Water temperature was tested throughout the visit, and water measured between 110 – 120 degrees Fahrenheit. Outside areas: The LPA and Executive Director toured the outside areas and courtyards. There was appropriate outdoor furniture, with a covered shaded area for residents observed in several facility courtyards. There is a locked pool for resident usage with appropriate fencing and it was locked inaccessible. For residents to use the pool, residents must check out a key from the front desk. Parking is available for residents and visitors. Files: Residents records review began at 11:50 a.m. Six (6) records were reviewed for, but not limited to: care plans, medical records, admissions agreement, consent forms. Resident records were in order. Six (6) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training. Out of the six (6) files reviewed, three (3) require valid first aid certification (Staff #1, Staff #2, Staff #3). Otherwise, records were in order. Facility conducts emergency drills regularly. Training records were reviewed, and no discrepancies were observed at the time of the visit. Medications: Medications review began at 2:30 p.m., Medications are centrally stored and locked in the Wellness Center on the third floor. For one resident (R1), the pill count was off for two medications (Xarelto, Escitalopram) by one pill, specifically for 7/10/2023. Staff checked R1's medical record (MAR) but it was indicated as administered on 7/10/2023. Not all medications were documented on the centrally stored medications and destruction record (CSMDR) for 4 out of 5 residents (R1, R2, R3, R4). However, staff re-requested the CSMDR forms from the pharmacy during today's visit. Technical violation issued. Documentation: The LPA obtained a copy of the liability insurance, Infection Control Plan, resident roster, and staff roster. Pursuant to Title 22 of the 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 issued.