Routine inspection·October 14, 2023

On 10/14/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Executive Director Ralph Balbin. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to serve (150) non-ambulatory elderly residents of which (30) may be bedridden ages 60 and above. The facility is approved for (20) hospice residents. Currently, the facility has (16) hospice residents. The facility is a three-story structure located in a residential neighborhood. It consists of the following: (27) resident bedrooms in the Neighborhood and (114) resident bedrooms in Assisted Living. Each room has a bathroom in the unit, a lobby, a living room, (3) lounge areas, a dining room, a kitchen, a bistro, a Memory Care Unit. housekeeping/janitorial storage closets, (3) administrative offices, (2) laundry rooms, an activity room, a Wellness room, an engineering office, a beauty salon, an activity area, front and rear patio area, a gated pool, and outdoor storage sheds. LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #135, #138, #245, #253, #322 and #330. All call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.7 – 115.4 degrees F. A comfortable temperature was maintained in the facility at 72 - 74 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. (Evaluation Report continues LIC 809-C) Fire extinguishers were fully charged, and smoke detectors and carbon monoxide were operable in each resident's room. The facility conducted an emergency fire and earthquake drills on 09/20/23. The facility has certificate of liability insurance effective 10/01/23 - 10/01/24. The facility is current on annual (CCL) license fees. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurate. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA conducted an audit of resident #1-#6 (R1-R6) service files, and staff #1-#6 (S1-S6) personnel files were in maintained in place. LPA conducted (5) residents and (3) staff interviews. Deficiency: During staff file review between 12:30pm - 2:30pm, the following required items were not in the files: (3) out of (6) staff #2, #4, #5 care staff did not have have current CPR/First aid on file. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D). An exit interview conducted with Ralph Balbin, and a copy of the report and appeal rights provided. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *