Routine inspection·October 28, 2021

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Licensee, Amber Branconier who assisted with the visit. The facility has a capacity of 120 residents. It is licensed to serve elderly residents age 60 and above, approved for 120 non ambulatory residents of which 21 may be bedridden. The facility has five (5) Hospice Waiver for on file. Annual licensing fees are current. LPA discussed the purpose of today's visit. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility is a two-story building with 60 resident rooms. Facility consists of Lobby/Reception Area, office, medication room, Activity Room, TV/Entertainment Room, Beauty Shop, Employee Room with lockers and time clock, laundry room, kitchen, and dining room. Medications were centrally stored. Medications room was locked and inaccessible to residents in care. Seven residents’ medication records were reviewed. Hallways were clean and free of obstructions. Common areas were well organized and free of hazards. LPA inspected Resident room # 102A, 103B, 105B, 117A, 119A, 122A, 215A, 225B, and 230A. Resident bedrooms had furniture, lighting fixtures and personal storage space as required, mattress pads observed on all beds, the required amount of linen also observed. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 115.5 to 118.4 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies. Signal systems were tested in resident rooms. The system was operable and staff responded to resident rooms within five minutes. Last Fire Drill was conducted March 16, 2021. Administrator certificate is current with expiration date on 2/13/2022. (-continued in LIC 809 C-) Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens and counter tops observed to be clean, plates, cups, glasses and utensils for the current census. A comfortable temperature of 74 degrees Fahrenheit maintained throughout the entire facility. Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged. Audio devices were operable. First aid kits were fully stocked with manual. All mandated documents and signages are posted in common areas. Side and front yards are well maintained and free of debris. There is shaded outdoor area with ample seating. No bodies of water observed. Deficiency was cited per California Code of Regulations, Title 22. An exit interview was conducted. This report is discussed and provided to facility Licensee, whose signature on this form confirm receipt of these documents.