Routine inspection·April 24, 2025

Licensing Program Analyst (LPA) Daniel Konishi conducted the Unannounced required annual inspection. LPA arrived unannounced and met with the Executive Director, Mary Mims-Burris and assisted with the visit. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. The fire clearance is approved for 49 ambulatory and 111 non-ambulatory. Currently, the facility has 11 hospice waiver residents and 3 home health residents. On today's date, LPA inspected the eight (8) domains include: Infection Control, Operational Requirement, Physical Plant Environmental Safety, Resident Right-Information, Planned Activities, Food Services, Incidental Medical and Dental, Disaster Preparedness. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Operational Requirement: T he current plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 15 residents is approved. A fire clearance approved for 49 ambulatory and 111 non-ambulatory with no bedridden residents. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($2,000,000) is in place. Physical Plant and Environmental Safety: The facility is a three-story building. The first floor includes memory care unit and assisted living resident's rooms, main lobby, administrative office, Bristol, wellness director office, two activity rooms, resident coordinator office, assistant director office, Chart room, Library, Multi-purpose room, resident mailbox, community laundry room, dining room and facility kitchen. The 2nd floor includes laundry room, activity room, unisex bathroom and assisted living residents' rooms. Physical Plant and Environmental Safety [Cont.]: The 3rd floor include laundry room, activity room, exercise room and unisex bathroom and assisted living residents' rooms. During the facility tour, LPA inspected Room #106, #108. #122, #123, #218, #220, #221, #320 and #321, #335, #351 and they all have sufficient lighting and required furniture in the residents’ rooms. For the resident bathrooms, they are clean, sanitary and in a good working condition. All the residents’ bathrooms have the required Nonskid mat and grab bar in the bathtub and toilet. LPA tested the hot water temperature and they are between 116.8-degrees F and 123.4-degrees F (Rm#106 was 122.1 degrees F, Rm#108 was 123.2 degrees F, Rm#218 was 123.4 degrees F, Rm#220 was 121.8 degrees F, Rm#335 was 122.8 degrees F, and Rm#351 was 121.4 degrees F) which are not within the Tittle 22 regulation. The carbon monoxide detector is located in the laundry room and it's working properly. LPA reviewed the annual fire inspection and testing report via the state fire marshal and everything is working well. All the cleaning solutions and chemicals are locked in the janitor room and inaccessible to the residents. Facility has a telephone service on the premises. The backyard / rear grounds of the facility is well landscaped and the passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris and the trash can or containers have the covered lids. Resident's Right Information: LPA observed the required posters posted nearby the residents' mailbox which include Long Term Care Ombudsman, Community Care Licensing Complaint and Personal Right Poster. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted and LPA reviewed the calendar for both Assisted Living and Memory Care Unit. The facility does have an active Resident Council. Food Services: Currently the facility has about 3 residents in the Assisted Living and 2 residents in the Memory Care Unit are required to have modified diet. The facility has ample supply for two days perishable and seven days non-perishable food supply. The facility kitchen is clean and kept free of litter, rodents and insects. All food in the facility are stored properly. [Continue in LIC809-C] Incidental Medical and Dental: LPA inspected twelve (12) residents' medication which include nine (9) from Assisted Living and three (3) from Memory Care Unit and they are centrally stored and locked in the medication room and they seemed accurate and updated and also contained 30 days’ supply of medication. The facility would also provide medical and dental transportation if needed Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610E) and it’s updated on 01/08/2025. The last fire drill was conducted on 03/11/2025. The facility has two temporary alternative shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training. Due to time restraint and LPA was not able to complete the full inspection tool and interview residents and staff and LPA will come back at another time to complete. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit Interview conducted and a copy of the report with appeal rights were provided to the Executive Director, Mary Mims-Burris.