Routine inspection (multi-day)·May 30, 2024

License Program Analyst (LPA) Shannan Hansen arrived at 8:45 AM to complete an unannounced annual inspection and met with Mary McClure, Administrator. There is a total of 26 memory care residents. During inspection 5/29/24 LPA observed 3rd floor west fire exit obstructed by bedframe across interior of both exit doors, and a full bed in front of one of the exit doors on the east side of the 3 rd floor, which is a violation of Fire Safety regulation 87203 (see pics & LIC809-D). During today’s inspection 5/30/2024 both bed & bedframe have been removed. During inspection on 5/29/24 at approximately 9:30am LPA observed unwrapped quiche in 3 rd floor kitchenette drawer, unwrapped/uncovered ice cream in freezer & uncovered pie from previous day in refrigerator (see pics LIC809-D). LPA also observed on 3 rd floor, black coloring on floor under kitchenette sink where water leak use to be, a missing bedroom door to room 314 & bathroom wall to resident (R1)’s room (see pics & LIC 809-D). Razors & a pair of scissors were observed by LPA & BOD on 5/29/2024 at aprox 9:45 am in R2’s unlocked bathroom cabinet. BOD moved immediately (see pics & LI809-D). At approximately 11:30 pm, LPA reviewed 5 staff records. 2 of 5 staff Dementia training records were not complete & 2 of Medication training records did not contain required hours of training (see LIC 809-D) Evidence of current first aid and CPR training were present for required staff. All staff had required criminal record clearance and were associated. LPA reviewed centrally stored medication records of 2 of 2 residents finding to be complete to complete this annual inspection. Continued on LIC 809-C Fire extinguishers were last serviced 9/25/2023. Fire safety system including smoke detectors and carbon monoxide detectors are checked quarterly by facility staff and are on a regular service schedule with a vendor, is current. Disaster Drill are conducted monthly in shift rotation with the last drill being conducted on 5/22/2024. Facility is being cited today for 87203 Fire Safety violation with an immediate Civil Penalty in the amount of $500. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.. LPA Hansen is requesting Licensee to update and submit the following documents by 6/13/2023 to SRRO: LIC 308 Designation of Facility Responsibility LIC 610 Emergency Disaster Plan (if changes) Proof of Liability Insurance