Routine inspection (multi-day)·December 7, 2023

Licensing Program Analyst (LPA) Galarza conducted an unannounced Annual Continuation visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Diana Bautista. The facility serves residents ages 59 and older. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is still in place at the front desk. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Operational Requirements: An Infection Control Plan has been added to the Plan of Operation. The facility has a Dementia Waiver in place and an approved Hospice Waiver for 20 residents. There are presently 23 residents enrolled in hospice care, which exceeds the approved waiver. Citation was issued. A fire clearance for 114 non-ambulatory residents; of which 15 may be bedridden is in place. There are 4 bedridden residents in care. 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 6/2/2024. No Surety bond is in place. Facility does not handle resident monies. ***Narrative continues next page.***** Physical Plant/Environment Safety: 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. Cleaning supplies and toxic substances are inaccessible to residents. The facility is a three (3) story building consisting of 77 resident rooms. The 1st floor consists of a lobby, dining room with outdoor courtyard, kitchen, medication room, administrative offices, electrical room, public restrooms, laundry room, 21 resident rooms, shaded outdoor courtyard area, and a Memory Care unit with multi-purpose room, and outdoor courtyard. The 2nd floor consists of 28 resident rooms, Bistro area, game room, public restrooms, 2 storage rooms, laundry/housekeeping room, outdoor shaded balcony area, and 2 common areas. The 3rd floor consists of 28 resident rooms, fitness room, theater room, lounge, beauty shop, and outdoor shaded balcony area. Delayed egress is in place in the 1st floor Memory Care unit. There are evacuation chairs on 2nd and 3rd floor stairwells to be used during an emergency as a path of egress from the facility to safety. On 7/24/2023, an annual fire inspection was conducted by Code Red Fire, Inc. The sprinkler system, alarms, fire connections, water flow alarms were inspected. The facility has fully charged fire extinguishers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Beds in rooms 107, 110, 115, 218 did not have mattress pads. Citation was issued. Staffing: A total of 49 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 8/15/2024. Staff have criminal background clearance and training, with exception of staff (S1). Citation was issued. Ten (10) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training was reviewed. Staff (S2-S6) did not have current 1st/Aid certificates. ***See next page. Resident Records/Incident Reports: A total of 10 resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, Individual Service Plans, and medication records. NOTE: Previous licensee's admission agreements are being used. Citation was issued. RCFE complaint poster and Personal rights were observed posted. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted in the entrance area. The facility has a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Incident Medical and Dental: Eleven (11) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medication errors were observed on 12/5/23, citations were issued. Medical and dental transportation is not provided at this time because the facility does not have staff/driver. Per Plan of Operation the facility shall provide transportation. Citation was issued. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Evacuation chairs in each floor were observed. Records of resident Appraisal and Needs services plans are part of Emergency training. *****See next page. Residents with Special Health Needs: Twenty three (23) residents are receiving hospice services, which exceed the approved waiver total of 20 residents. Five (5) residents receive home health services. Postural support physician orders are on file. Half bed rails for mobility assistance were observed in some resident rooms. Full rails were observed in hospice residents. Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were issued.