Routine inspection (multi-day)·June 12, 2024

At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Executive Director, Sam Faye, and Regional Health and Wellness Director, Roschelle Factor. 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 126 individuals, where 118 individuals can be Non-Ambulatory and 8 individuals can be Bedridden. Facility has an approved hospice waiver for 15 individuals. Upon arrival, LPA was informed that there were 70 residents in care and 23 staff members on-site. At approximately 9:25AM, LPA reviewed Facility Staff Roster with Executive Director and found that all staff members on site were background cleared and associated to the facility per regulation. LPA reviewed staff files. LPA observed that some staff did not complete their annual 2023 training (see LIC809D, Health and Safety Code, 1569.625(b)(2)). LPA reviewed First Aid/CPR certifications. LPA observed that medication technicians had appropriate certification. Direct Care Staff had first aid certification but it was not through a qualified medical agency. LPA received documentation regarding the first aid training that direct care staff received (see LIC9102, Health and Safety Code, 1569.618(c)(3)). LPA reviewed medications. LPA discussed with management regarding centrally stored medication and ensuring that it is written correctly in their central storage log (see LIC9102, regulation 87465(h)). Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator, and Regional Health and Wellness Director. Signature on form confirms receipt of documents.