Routine inspection·February 26, 2024

Licensing Program Analysts (LPAs) Emily Peraldi and Sandra Urena arrived at the facility unannounced to conduct a required annual visit. At 10:05 a.m., the LPAs were greeted and screened by staff. At 10:15 a.m., the LPAs met with the Executive Director (ED), Elizabeth Whittington and explained the reason for the visit. At 10:36 a.m., the LPAs 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. The facility is a five-story building. Resident rooms are located throughout four floors, all floors are assisted living except for floor three (3) which is designated for memory care. Common spaces on the first floor include the reception area/lobby, a theater, salon, 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. 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 01/05/2024. Fire alarm/sprinkler system test was documented and tested 08/2023. 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. The menu was posted, and the facility offers daily specials and a standard selection at every meal. Snacks and beverages are available for residents. Resident Units: The LPAs and Executive Director toured seven (7) randomly selected resident rooms throughout the community. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Continued on LIC 809C. Restrooms: The LPAs and Executive Director observed restrooms in seven (7) 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. Water temperature was tested throughout the visit, and water measured between 105.1 – 116.6 degrees Fahrenheit. Outside areas: There are multiple outdoor patios equipped with furniture for resident use. There were no bodies of water noted. Parking is available for residents and visitors. Files: Between 11:40 a.m. and 2:25 p.m., the LPAs conducted a file review for six (6) residents and six (6) staff. Six (6) resident records were reviewed for, but not limited to: care plans, medical assessments, admissions agreement, consent forms. Resident records were in order. Six (6) personnel records were reviewed for, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and training documentation showing required training completed. Personnel files were in order. Starting at 2:30 p.m., the LPAs conducted a review of medication records, policy and procedures with the Executive Director. Audit for seven (7) residents revealed that facility staff did not accurately record medications, and/or missing start dates. The Executive Director stated that facility staff will receive medication training. Documentation: The LPAs obtained a copy of the liability insurance, resident roster, and staff roster. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiency was cited (refer to LIC 809-D). The Executive Director was made aware that failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.