Routine inspection·March 30, 2023

On 03/30/23, Licensing Program Analyst (LPA) Lizeth Villegas and licensing program manager (LPM) Janae Hammond conducted an unannounced annual required visit using the CARE Inspection Tool. LPA and LPM met with the Administrator Peggy Clark and assistant administrator Veronica Gomez as the purpose of today’s visit was explained. The facility is licensed to operate for 262 non-ambulatory residents of which 10 maybe bedridden ages 60 and over. The facility has an approved Hospice Waiver for 10 residents. The facility is a large two-story building located in a residential neighborhood. The facility has a memory care unit and an assisted living unit; the assisted living unit consist of two floors which includes resident rooms, common area, dining area, kitchen, an outdoor shaded area, a laundry room, reception area and administrative offices. Memory care unit consist of two floors, resident rooms, dining area, common area, a theater, and delayed egress doors. The facility has a signal system with the switch board in the reception area and is operational from all resident living units. LPA and LPM conducted record reviews of (11) residents records, (10) staff records all which were complete. LPA and LPM reviewed (10) Client Medication Administration Records. The facility disaster plan and the last drill was conducted on Monday 03/27/23. The facility disaster plan is current and in compliance with Title 22regulations at the time of visit. LPA and LPM checked resident units, mattresses and box springs were in good condition, adequate lighting and plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to residents. The water temperature properly measured between 105F-120F. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector and smoke detectors were observed, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to residents. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Exits/ Walkways around the facility were free of debris and hazards. During today’s visit the following deficiencies were observed; During the review of Administrators Peggy Clark record review, it was observed that the Administrators certificate expired on 10/18/2020. LPA and LPM asked Administrator for a current Administrator certificate and Administrator reported she is currently taking her continued education units and has not recertified at this time. During the review of Medication Administration Records for resident number 1 it is observed that resident is diabetic and is receiving glucose checks and is receiving insulin injections. LPA and LPM inquired who is responsible for checking resident number 1 glucose and insulin injections and were informed that staff is responsible for checking resident’s glucose and staff assist residents with hand over hand insulin injection. LPA and LPM reviewed resident number 1 physician report which indicates resident is not able to administer glucose testing nor insulin injections. The administrator informed LPA and LPM that there are no appropriate skilled professionals working at the facility. Deficiencies cited under California code of regulations title 22, division 6, chapter 8 are being cited on attached LIC 809 D. Exit interview conducted with Administrator Peggy Clark, appeals rights explained, and a copy of this report was provided.