Routine inspection·July 3, 2024

At approximately 8:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection. Kristine Soriano, Resident Services and Independent Living Director was contacted and arrived at approximately 8:50 AM. Facility is an Continuing Care Residential Community (CCRC) with 328 residents in care. Community has a Hospice waiver for 15 with 4 residents currently receiving Hospice services. At approximately 9:10 AM, LPA initiated a tour of independent living facility with Director and observed the following: Facility has a two- and a three-story wing, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of paper products available to clients. At approximately 10:15 AM, LPA initiated tour of the assisted living and memory care facility with Mary Shcramm, Administrator of Assited LIving and Memory Support. The Assisted living wing is a two stories and memory care in one story. The facility was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of paper products available to clients. Cabinets containing cleaning supplies and other items that could pose a risk were locked. The community has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a covered patio, seating area and outdoor space for activities. LPA observed an activity schedule and a facility computers and internet available for resident use. LPA reviewed medications and medication records which are maintained in compliance with regulation. Continued on LIC809-C... Continued from LIC809... The community's fire extinguishers were observed charged and were last serviced January 2024. Smoke and Carbon Monoxide detectors were observed during inspection. Facility conducts regular bi-annual emergency/disaster drills, and LPA informed Director and staff that these shall be completed quarterly moving forward per regulation. The community's most recent drill was conducted June 2024. LPA observed facility's infection control plan and emergency disaster plan which was last updated April 2016. LPA observed a supply of PPE, emergency supplies, flashlights and a first aid kits throughout the community. Facility has a three backup generators. At approximately 1:30 PM, LPA reviewed ten (10) staff files and ten (10) resident files. Ten (10) of ten (10) staff files reviewed has the required current First Aid certificate and each has a current CPR certification as well. Each staff file reviewed had all the required paperwork per regulation. Four (4) of ten (10) resident files reviewed were missing the required updated annual physicians report and updated and signed reappraisal and care needs plan. LPA issued a citation for this (see LIC 809D). LPA observed all the remaining required paperwork in all ten (10) resident files reviewed. Administrator informed LPA that community coordinates medical and dental visits for the majority of their residents. LPA also obtained documents regarding recent IRs and SOC341 during inspection and will follow up with community at a later date. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit : LIC500- Personnel Report LIC610- Emergency Disaster Plan A copy of community Liability Insurance A copy of the property deed - proof of ownership 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 with Administrator and Appeal rights were given. Signature on form confirms receipt.