Routine inspection·April 1, 2025

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to Administrator Sarah Rafael. The Residential Care For Elderly (RCFE) facility serves residents ages 60 and over. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed. The facility has sufficient supply of Personal Protective Equipment (PPEs). Operational Requirements: The facility has a hospice waiver for 20 residents. A fire clearance for 100 non-ambulatory residents; of which 10 may be bedridden is in place. Facility handles resident monies and has set up trust accounts. The Surety Bond is current. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 11/1/2025. A technical advisory was issued regarding transportation van maintenance logs. Physical Plant/Environment Safety: The facility is comprised of a 3- story building that has 66 resident rooms, 2 activity rooms, TV room, Namaste room, 3 dining rooms, laundry room, 2 courtyard patio areas, and a Memory Care Unit. The interior and exterior physical plant was inspected. A total of 18 randomly selected resident rooms were inspected. Beds have required bedding, linens, and mattress pads. The signal system was tested and is operational. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Cleaning supplies and toxic substances are inaccessible to residents. Exit doors are free of any obstruction and there are no pools or large bodies of water. Delayed egress is in place in the 1st floor Memory Care unit. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has charged fire extinguishers. The last fire inspection was conducted on 1/24/2023 by City of San Gabriel Fire Department. Staffing: A total of 42 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 12/15/2026. Staff have criminal background clearance. Seven (7) staff files were reviewed. They contained 1st Aid/CPR training, criminal background clearance, health/TB screenings, 1st Aid/CPR training, and training records.. Administrator certificate expires 12/15/2026. Resident Records/Incident Reports: Ten (10) resident files were reviewed. They contained admission agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Centrally stored medication records were reviewed. RCFE & Ombudsman complaint poster are posted in the main entrance hallway. Planned Activities: Facility activities are conducted in the AL dining room and 3rd floor activity room. Memory Care unit resident activities are held in the dining room area. Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted. The facility has a Resident Council. Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Twenty eight (28) residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Dining Services Director's Food Handling Certificate is current. Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family or 3rd party transportation companies. The facility has a van with current insurance and registration. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 1/24/25. Residents with Special Health Needs: There are currently 3 residents receiving hospice services, 4 receive home health services, and no residents have prohibited health conditions. Individual Service Plans and Appraisals are on file. Postural support physician orders are on file. Half and full bed rails for mobility assistance were observed in some resident rooms. Resident (R10) had two half rails on one side, but is not enrolled in hospice. Therefore, a citation was issued. Per California Code of Regulations, Title 22, a deficiency was cited. Exit interview, copy of report/appeal rights was conducted with Administrator Sarah Rafael.