Routine inspection·July 11, 2024

Licensing Program Analyst (LPA) Galarza a nd Research Data Analyst Michael Moriel con ducted an unannounced annual inspection visit. The purpose of the visit was explained to Designee Administrator Claudia Sanchez. The facility serves elderly residents ages 60 and older. A hospice and Dementia waiver is in place. It consists of 48 resident rooms in a 2 story main building and 2 detached buildings, 1 activity rooms, dining room, laundry area, 2 courtyard patio areas, and one 2nd floor balcony. 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: A hospice waiver for 15 residents has been approved. A fire clearance for 48 ambulatory, 32 non-ambulatory, of which 7 may be bedridden is in place. Facility handles resident P & I monies for a total of 10 residents. However, the licensee does not have a Surety Bond. 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 8/26/2024. 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 last fire drill was conducted on 6/17/2024. The facility has fully charged fire extinguishers. The signal system was tested and is operational. Water temperature readings did not measure d within the required 105 - 120 degrees Fahrenheit. Water temperature readings measured between 92.8 DF - 136.9 DF . Stairwell evacuation chairs were observed. *Note: Blue tarps were observed on the roof. Elevator is not operable at this time. Staffing: A total of 15 staff members provide care and supervision to the clients. Administrator Stephany Perez is a corporate office staff. Designee Administrator Claudia Sanchez is in charge of daily on-site operations. Personnel Records/Staff Training: Administrator certificate is current. Staff have criminal background clearance and training. Six (6) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training was observed. Resident Records/Incident Reports: A total of six (6) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, and medication records. 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. The facility does not have 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.11 residents are on modified diets. Physician orders are on file and special diet lists are kept in the kitchen area. The freezer door thermometer is not operable, but 2 portable thermometers were observed inside. Incident Medical and Dental: Six (6) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by Access or insurance transportation services. Facility has one (1) van for resident transport, but is presently not working. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Evacuation chairs are in place. The elevator is inoperable. All non-ambulatory residents are on the 1st floor. Facility has a First Aid Kit and Manual. Residents with Special Health Needs: Four (4) residents are receiving hospice services and one (1) resident receives home health services. Nine (9) residents have a Dementia diagnosis and are located in the 1st floor. Postural support physician orders are on file. Full bed rails for mobility assistance were observed in some resident rooms. No residents have prohibited health conditions. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Claudia Sanchez A copy of the report and appeal rights was issued.