Routine inspection (multi-day)·November 15, 2024

Licensing Program Analyst (LPA) Galarza conducted an unannounced Annual Continuation visit. The purpose of the visit was explained to Administrator Diana Bautista. There facility serves residents 60 years and older. The following 12 (CARE) tool domains were utilized during the inspection. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed. The facility has a supply of Personal Protective Equipment (PPEs). Operational Requirements: The facility has a Dementia plan, a fire clearance for 114 non-ambulatory residents age 60 and above, of which 15 residents may be bedridden, and a hospice waiver for 30 residents. Facility does not handle resident money. 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 5/20/2025. Physical Plant/Environment Safety: 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. *See 809C pages. continuation - 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 equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has fully charged fire extinguishers. Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. 12 out 22 resident rooms and a kitchen sink hot water readings measured between 120 DF 124.2 DF. On 6/28/2024, County of LA Fire Department conducted an annual inspection.The sprinkler system, alarms, fire connections, kitchen hood, and water flow alarms were inspected. Violations were found. All maintenance records shall be kept in the facility. Re-inspection will be conducted on 11/20/2024. Staffing: A total of 63 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expired 8/15/2024 and is pending approval from CCL Recertification Unit. Staff have criminal background clearance. Eleven (11) staff files were reviewed. 9 out 11 staff files had expired 1st Aid/CPR training or no proof of training. 6 out 11 staff files do not have required annual training hours. 2 out 11 staff files do not have health and TB clearance. 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 are in place. RCFE & Ombudsman complaint poster 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. Twenty six (26) 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 expires 11/16/2025. 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 non-operable van and no staff driver. An medication error was observed during medication review. Two (2) of Resident (R1's) medications listed on the Medication Administration Record were not filled. Acetaminophen 325 mg, 2 tabs every 4 hours PRN for fever over 100DF & Acetaminophen 325 mg 2 tabs every 6 hrs PRN for mild pain. 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 9/23/2024.. Residents with Special Health Needs: There are currently 19 residents are receiving hospice services, 6 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 bed rails for mobility assistance were observed in some resident rooms, as well as full rails were observed in hospice residents. 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 was issued.