Routine inspection·December 20, 2023

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Executive Director, Donna Daniel-Herr and Assisted Living Director, Mary Ann De Lara. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for a total capacity of 130 individuals, where 81 individuals can be Non-Ambulatory and 15 can be Bedridden. Facility has an approved hospice waiver for 10 individuals. Upon arrival, LPA was informed that there were 93 residents in Assisted Living and Memory Care with 21 Independent Living residents for a total of 114 residents in care. LPA was also informed that there were 22 staff members on-site. At approximately 9:45AM, LPA reviewed Facility Staff Roster with Assisted Living Director and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 10:15AM, LPA conducted a walk-though of the facility with Assisted Living Director and observed the following: Facility is a 3 story building for Assisted Living and Memory Care, and has separate Independent Living units on the property. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 10 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. At approximately 11:30AM, LPA reviewed 5 resident files and 5 staff files. Resident Files were all found to be well organized, thorough and contained the required documentation. LPA observed that 4 of 5 staff files were missing all or parts of the required annual training per Health and Safety Code (this deficiency has been cited, see LIC809D, Health and Safety Code 1569.625(b)(2)). Continued on LIC809C Continued from LIC809 Facility's fire extinguishers were last inspected April 2023. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected February 2023 and October 2023. Facility's last fire/disaster drill was conducted October 2023. LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.