Routine inspection·September 13, 2024

On this day, Licensing Program Analysts (LPA) Alvaro Ramirez, Jr. made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry to facility by Business Office Manager (BOM) Sharin Belanger. LPA Ramirez toured the interior and exterior portions of the facility with BOM Belanger. During this visit, there are a total of 21 staff members on duty. The facility is a three level structure and is licensed for 155 non-ambulatory residents, of which 15 may be on hospice and 0 may be bedridden. Currently, there are a total census of 119 residents in care. LPA Ramirez initiated random bedroom checks, of which bedrooms were observed to have furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Water temperature in restrooms were measured to be between 111.0-115.8 degrees Fahrenheit. Smoke and carbon monoxide detectors were operational and most recent fire inspection took place on August 06, 2024, of which inspection was passed. Auditory alarms and wander guard functions were also tested and observed to be operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. LPA Ramirez also tested pull cords in resident bathrooms, and observed to be operational. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Facility had back-up emergency food and water supply. LPA toured the kitchen and observed the weekly food menu. LPA also observed handouts for Resident Programs Daily Events which included express manicure, Jeopardy Wii and Spanish 101. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and located in multiple areas of the facility. LPA observed exit stairwells and each floor had an evacuation chair. Facility does not have delayed egress doors. CONTINUED ON LIC809-C... For the exterior portion, LPA Ramirez observed patio furniture under shading, and the grounds were free of any hazards. LPA observed the emergency disaster and evacuation plan, which is posted at the main entrance behind the front desk. LPA Ramirez observed that First Aid Kit had all the required components. Medications were locked and inaccessible to residents in care. Toxins were also observed to be locked and inaccessible to residents. During the tour LPA did not observed the Elderly (RCFE) Complaint Poster (PUB 475), a Deficiency was issued today. LPA reviewed ten resident files and five staff files. LPA observed that five of five staff records reviewed did not include a Health Screening Report, a Deficiency was issues today. For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued. LPA Ramirez advised BOM Belanger to use the general email address: CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA. LPA Ramirez conducted an exit interview with BOM Belanger and a copy of this report was provided to the facility.