Routine inspection·January 21, 2023

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required Annual Visit focusing on COVID-19 Infection Control Practices. LPA was met by Haven Program Manager Daniel Orozco and explained the purpose of the visit. Executive Director Cecilia “CC” Degraff arrived shortly after to assist in the tour. 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. Physical plant was toured and food supply was reviewed. Last fire drill was conducted on 01-10-2023. LPA OBSERVATIONS: · The first floor is Assisted Living and consists of 44 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) Connections with 24 rooms for residents with mild to moderate dementia and 2) Haven with 21 rooms for late to end stage dementia. Each unit has a dining area, kitchenette , 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. · Assisted Living- LPA toured resident rooms 101 and 202. LPA observed each bedroom to contain the required furniture and linens. Each room was observed to have its own bathroom. Bathrooms were observed to be clean and equipped with operational 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. Water temperature in resident room 101 was measured at 105 degrees F which is following Title 22 Regulations. Water temperature in resident room 202 was measured at 105.4 degrees F and is following Title 22 Regulations. · Haven- LPA measured water temperature in kitchenette area at 114.8 degrees F which is within the required 105 – 120 degrees F. LPA toured resident rooms 202, 218, and 225. LPA observed each bedroom to contain the required furniture and linens. Rooms 225 and 202 were observed to have their own bathroom. Water temperature in resident bathroom 202 was measured at 105 degrees F which is following Title 22 Regulations. Water temperature in resident bathroom 225 was measured at 118.2 degrees F which is following Title 22 Regulations. Resident bathroom 218 is a shared bathroom and water temperature was measured at 113.2 degrees F which is following Title 22 Regulations. Bathrooms were observed to be clean and equipped with operational grab bars. 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. · Connections- LPA measured water temperature in kitchenette area at 106.7 degrees F which is within the required 105 – 120 degrees F. LPA toured resident rooms 229, 231, and 235. LPA observed each bedroom to contain the required furniture and linens. Room 229 was observed to have its own bathroom. Water temperature in resident bathroom 229 was measured at 105.2 degrees F which is following Title 22 Regulations. Resident bathroom 231 is a shared bathroom and water temperature was measured at 105.7 degrees F which is following Title 22 Regulations. Resident bathroom 235 is a shared bathroom and water temperature was measured at 105.6 degrees F which is following Title 22 Regulations. Bathrooms were observed to be clean and equipped with operational grab bars. 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 kitchen was observed during lunch time to be clean, and staff were observed to be wearing gloves while preparing lunch for residents. There was a sufficient amount of perishable and non-perishable food supplies. LPA observed perishable foods were stored in covered containers at the appropriate temperatures. No pesticides or poisons were stored in the food areas. Storage areas for cleaning solutions, toxins, 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. No deficiencies were observed during visit. An exit interview was conducted, and a copy of this report was provided to the Executive Director.