Follow-up·January 19, 2024

At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit to follow up with facility regarding a previous request for a bedridden fire clearance. Prior to this visit, LPA met with the Fire Department to discuss modifications needed prior to the approval of the request. LPA met with Administrator Agnes Ajel and reviewed the items requested by the fire department. Due to the time frames involved for the required additions, Agnes has agreed to retract the request at this time and will resubmit when the additions are complete. The facility, LPA and Fire Department will work together to formulate a plan, with time frames of completion, for the additions needed to allow facility to re-apply for the clearance. The following items will be outlined in the plan: - Integrated fire system, including audio/visual alerts, sprinklers and pull stations - widening of doorways - fire doors - ensuring exit paths are wide enough for emergency personnel These items are not intended to be a complete list of requirements, as there may be more items found that need to be addressed. LPA discussed the facilities disaster plan and disaster drills. The facility has not been compliant with conducting drills as required. LPA requested an updated disaster plan, which describes how facility staff will safely evacuate residents, including bedridden residents, in case of an emergency. LPA provided regulation 87212 and 87606 for review. 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. This report was reviewed with Agnes Ajel and Appeal rights were given.