Routine inspection·December 7, 2024

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a required annual inspection on 12/07/2024. LPA met with Lupe Jaime (House Keeping/Purchasing Supervisor) and discussed the purpose of today’s visit. The facility is licensed for ninety-nine (99) non-ambulatory residents, age 60 and over. The facility has an approved hospice waiver for nine (9) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants and cleaning solutions that could pose a danger if readily available to residents, were observed to be accessible in resident room#118. Staff removed disinfectant and cleaning solutions after LPA Ramirez made observation. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected seven (7) resident rooms. All resident bedrooms contained required furniture, linens, and lighting. Water temperatures in grooming and bathing areas were measured to be above 120 degrees F. 1 st floor communal bathroom sink water temperature was measured to be 129.4 degrees F, during inspection. Resident room# 112, bathroom sink water temperature was measured to be 122.7 degrees F during inspection. Resident room# 213, bathroom sink water temperature was measured to be 124.0 degrees F during inspection. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed emergency call cords to be operational. LPA Ramirez observed video surveillance in common areas of the facility. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). LPA Ramirez observed facility weekly and daily menu, which is approved by the facility certified dietary manager. LPA Ramirez observed kitchen staff preparing for lunch while wearing hair nets and gloves. LPA Ramirez observed several dining room servers disinfecting tables and counters while wearing gloves and hair nets. See 809-C for continuation. Planned Activities: LPA Ramirez observed an activities calendar for December of 2024 with various activities and outings for residents. LPA Ramirez observed sufficient outdoor space. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed evacuation chair in stairway. Last documented emergency drill was conducted on 11/06/24 and 10/03/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. Operational Requirements: The facility is licensed for ninety-nine (99) non-ambulatory residents, age 60 and over. The facility has an approved hospice waiver for nine (9) residents. LPA Ramirez reviewed facility liability insurance and auto registration for one (1) facility vehicle. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez did not observe documented required initial training for S1 and S2. LPA did not observe completed 20 required annual training hours for S1, S2, and S3. S1 completed 9 out of 20 required annual training hours. S2 completed 10 out of 20 required annual training hours. S3 completed 9 out of 20 required annual training hours. Staffing: Administrator Certificate for Lauren Chon and it expires 10/09/2025. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. Four (4) deficiencies were observed and cited during inspection. Exit interview was conducted and a copy of this report, 9099-D, and appeals rights was provided.