Routine inspection·October 24, 2024

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to the Executive Director, Rachelle Reyes and was granted entrance into the facility. The Administrator assisted with the tour of the facility. There are seventy-seven (77) residents who currently reside within the facility. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility has a current Infection Control Plan on file in place. Physical Plant/Environment Safety: The facility property is a two-story commercial building, licensed to serve 80 non-ambulatory residents ages 60 and above, of which 10 can be bedridden. The designated rooms for bedridden residents are rooms 1, 3, 5, 7, and 9, The facility has an approved hospice waiver for 30 residents. There are a total of 40 resident rooms. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility has six (6) fully charged fire extinguisher located in the front entrance and hallways and inspected on 03/29/2024. Cleaning supplies were observed in a secured area away from food in the kitchen. Carbon monoxide detector is tested and in working condition. There is an emergency sprinkler system throughout the facility. Water temperature readings measure between the required 105 - 120 degrees Fahrenheit in compliance with Tile 22 Regulations. Operational Requirements: The Program Design was reviewed. Care and supervision to meet the clients’ needs was observed. Liability Insurance is confirmed and currently on file. Staffing : A total of twenty-six (26) full-time staff members provide care and supervision to the clients. Personnel Records / Staff Training : Administrator certificate expired on 08/15/2024 and currently pending renewal. Staff have the proper criminal and background clearance. Seven (7) staff files for First Aid and CPR training, Personnel Record, Health Screening, TB Clearance, and Employee Rights. All other ongoing training was documented. Resident Rights/Information Physician orders were reviewed in resident files. Personal Rights is posted. Facility provides phone and internet access to residents. Resident Records/Incident Reports: Eight (8) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, and medication records were reviewed. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Planned Activities: LPA observed facility has sufficient activities, activity director, and sufficient indoor and outdoor space for planned activities. Incident Medical and Dental: Resident medical and dental records in resident files. Facility provides transportation for residents to medical and dental appointments if needed. All medications are centrally stored in Medication Room and are properly labelled and in their original containers. LPA reviewed 8 residents medications with no issues. Disaster Preparedness: Emergency and Disaster Plan was publicly posted and found within the facility. An emergency/disaster drill was last conducted on 08/13/2024. Residents with Special Health Needs LPA observed from record review and interview that the facility has no residents with special health needs. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report was provided to the Executive Director, Rachelle Reyes.