Routine inspection (multi-day)·December 18, 2024

At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a 1-Year Required Visit and met with Director of Nursing, Bridget Geist, and Administrator, Paul Duranczyk. Facility is a Continuing Care Retirement Community (CCRC) and has a portion of the property licensed as a Residential Care Facility for the Elderly (RCFE). This portion of the property provides care and assistance for Older Adults in Assisted Living. Facility has an approved fire clearance and capacity for 28 Non-Ambulatory or Bedridden Residents. Facility has a Hospice Waiver for 5 individuals. Upon arrival, LPA was informed that there were currently 12 residents in care and 3 staff members on-site. LPA reviewed the Facility's Staff Roster with Director of Nursing and found that all staff members on site were background cleared and associated to the facility per regulation. LPA reviewed staff and resident files, and resident medications. Staff files were found to be well organized, thorough and contained the required documentation. LPA reviewed a sample size of 5 resident files. During review, LPA observed Resident 1 and 2, (R1 and R2) did not have a negative TB test on file (deficiency cited, LIC809D, regulation 87458(b)(1)). Medication was centrally stored and secure. During medication review, LPA observed that the facility uses a written Medication Authorization Record (MAR) and a centrally stored log. LPA observed that some medications had incorrect medication expiration and fill dates, while other medications were correctly documented per regulation. LPA and Director of Nursing discussed reviewing centrally stored medication log and documentation expectations (see technical violation, LIC9102, regulation 87465(h)(6)). Administrator's Certificate for Paul Duranczyk (7010307740) was current with an expiration date of 10/26/2025. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.