Routine inspection·April 22, 2025

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA met with Asst. Administrator Martha Rosas and explained the purpose of the visit. Afterwards, Executive Director Pam Ogot arrived and assisted LPA with the inspection. Facility is licensed for 45 non-ambulatory, maximum of (8) hospice residents and (4) bedridden residents ages 60 and over. Currently, there are (45) residents in the facility who are 60 years and older, of which (1) is bedridden and (4) are receiving hospice care. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has an Infection Control Plan. Staff are adhering to infection control requirements. Emergency and disaster plan was completed and up to date. Infection control practices and Personal Protective Equipment (PPEs) were maintained. Operational Requirements: The Infection Control Plan has been added to the Plan. Facility accepts and retains residents with dementia. Approved Dementia Care Plan is in their plan of operation. There is no separate memory care unit inside the facility. Facility is approved for (8) hospice residents. Liability Insurance is in place . Surety bond in the amount of $10,000.00 is current. Fire drill was last conducted on 03/20/2025. Physical Plant/Environment Safety: At 10:15am, LPA along with Asst. Administrator toured the facility. The facility is a 2 story building located in a residential community. The grounds in the facility are well landscaped and have a leveled walkway to the entrance of the building. The facility consists of: First floor: Lobby, Administrative offices, Medication room, Laundry room, (1) Elevator, Large Dining area, Kitchen, Pantry, Activity room/patio, Storage room, Patio by the main entrance, and resident rooms. Second floor: Resident bedrooms, Beauty shop, Activity room and a community shower. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility is equipped with cameras in the common areas. E ach residents' room has their own restroom. In some of the observed bathrooms, there were no grab bars and non-skid mats. The exit points of the building, including the residents' living units, had no signal systems. Cleaning supplies and toxic substances are inaccessible to residents. At 10:30am, LPA tested hot water tempera ture in six (6) random resident rooms (Rooms #5, #6, #9, #209, #212, #216) in the first & second floors and t he water temperature readings were below the required 105 - 120 degrees Fahrenheit. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operational and compliant. The fire extinguishers were observed throughout the facility and are fully charged. Pull Fire alarm system observed and connected to the City of Monrovia Fire Department. Delayed egress devices in place. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. *****CONTINUED ON LIC809-C***** Staffing: A total of (32) staff members provide care and supervision to the residents, including the Administrator. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, hav e training and associated to the facility . Administrator's certificate expired on 09/15/2024, and renewal is still pending. Personnel Records-Training: LPA reviewed (6) staff files. Proof of staff training, health clearance, vaccinations, food handling certificates, and 1st Aid/CPR training are current. Resident Rights-Information: Resident personal rights, complaint hot line information and visitors policy posters are posted in the lobby by the main entrance. The facility provides internet service to all residents and have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted in the hallway. The facility has a Resident Council and council members/residents meet on a monthly basis. Food Service: Sufficient food supply is stored in the kitchen and pantry area consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. LPA observed unlabeled food containers in the freezer and refrigerator. Incident Medical and Dental: . Medications are centrally stored and properly labeled in their original containers or bubble packs. First aid kits are maintained in the medication room and in the front office. LPA reviewed multiple residents medications in the medication room with no issues observed. Medical and dental transportation is provided. Resident Records/Incident Reports: A total of (10) resident files were reviewed. They contained Admission Agreements, Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical Consent, Medication Records, and P & I Money Records. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Facility provides training on staff's responsibilities during an emergency or disaster. Residents with Special Health Needs: (5) residents are receiving home health services. (4) residents are under hospice care and (1) is bedridden. Facility admits residents with dementia and staff files reviewed today all have required training documented. LPA observed half bed rails for mobility assistance in some resident beds. Physician orders for postural support are on file. There are no residents with prohibited health conditions. Residents who are using oxygen have "No smoking In Use" signs posted on the residents doors. Pursuant to California Code of Regulations, Title 22, deficiencies were cited on the attached 809-D and Technical Violation, Technical Assistance were issued. Exit interview conducted and a copy of the report was provided to Pamela Ogot, Executive Director and Martha Rosas, Assistant Administrator.