Routine inspection·March 3, 2022

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted a site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Director of Nursing / Stephanie Peck and Wellness Nurse / Daniel Orozco and was later joined by the Executive Director / Cecilia "CC" Degraff who assisted with the visit. The facility is licensed to serve for a capacity of 106 residents (90 Non-ambulatory and 16 Bedridden) ages 60 and above. The facility has an approved Hospice Waiver on file for twenty (20) Residents. The Kensington Sierra Madre has an approved Dementia Care Plan in its plan of operation and accepts/cares for residents with dementia. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The first floor consists of 41 resident rooms, lobby/reception area, parlor, art studio/gallery, cinema room, library, dining room, cafe area and main kitchen. The second floor consists of the Memory Care Units, 1) Connection with 19 rooms for residents with mild to moderate dementia and 2) Haven with 15 rooms for late to end stage dementia. Each unit has a dining area, kitchen, activity area, living room and patio. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. No large bodies of water were observed. There are no security bars or weapons on the premises. The facility has central air and heating accommodations. LPA toured a random selection of resident rooms. Resident rooms were furnished appropriately. Each resident room has their own bathroom. The bathrooms were observed to be clean and operational w/grab bars. The resident rooms have signal systems located in each bathroom and facility phones to call the front desk. The signal system was tested in various locations and is operable. The hot water temperature was tested throughout the facility. (Please see LIC 809C for additional information) The kitchen was observed. There was a sufficient amount of perishable and non-perishable food supplies and perishable food was stored in covered containers at the appropriate temperatures. No pesticides or poisons were stored in the food areas. Storage areas for cleaning solutions, toxics, knives, and hazardous items were secured and made inaccessible to Residents. The fire extinguishers were observed to be fully charged and in compliance. The facility has carbon monoxide detectors in each resident room and in the hallways of the facility. A shaded area with chairs is provided to the residents. Medications are centrally stored in the locked medication carts located on each floor. A random selection of medications were reviewed to ensure they are being administered as prescribed and prescription and non-prescription PRN medications have signed and dated written orders from the physician. The following deficiencies were observed during today's visit; Between the hours of 10:45am - 12:30pm, the hot water temperature was tested throughout the facility and not measured within Title 22 Regulation guidelines. Men's room located on the first floor (near the bistro/parlor) was measured at 123.8 degrees F. Kitchen in Connection was measured at 123.9 degrees F. Activity room in Connection was measured at 121 degrees F. Kitchen located in room #238 was measured at 121 degrees F. Kitchen located in room #219 was measured at 122.5 degrees F. Bathroom located in room #219 was measured at 120.4 degrees F. Kitchen located in room #223 was measured at 120.5 degrees F. Kitchen in Haven was measured at 122.8 degrees F. Activity room in Haven was measured at 121.6 degrees F. At 11:26AM, Peroxide Multi Surface Cleaner /Disinfectant Spray and Vision Lens Cleaner were found in room #230, which is located in Connection. At 12:42pm, LPA discovered the following PRN medications were prescribed by Resident 1's (R1's) physician but were missing from the facility. ENEMA 19G-7G/ ML (Administer 1 Enema rectally every 48 hours as needed for constipation) & MI-ACID 400-400-40 MG (Take 2 tablespoonfuls 30ML by mouth every 4 hours as needed). The following deficiencies were observed to be in violation under California Code of Regulations Title 22. (refer to 809D). An exit interview was conducted and a copy of this report was provided to the Executive Director along with the appeals rights.