Routine inspection·November 6, 2024

Licensing Program Analysts (LPAs) Claudia Gutierrez and Eboni Bentley made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs met with Assistant Administrator (AAD) Alexis Jones and explained the purpose of the inspection. During the inspection, LPA Gutierrez and Staff Monserrat Pasillas conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and observed the following: This is a two-story building, licensed for one hundred non-ambulatory and one hundred ambulatory with a hospice waiver for ten. Evacuation chairs were observed at every stairway. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. There are two separate courtyard areas that include shaded sitting areas. LPA observed residents socializing in common areas and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 106.3 – 117.3 degrees Fahrenheit. LPA observed the facility has an excess of 2-day supply of perishables and a 7-day supply of non-perishable food. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguishers located throughout the facility were observed to be fully charged with service tags dated March 5, 2024. Appliances were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication was observed to be locked within the medication room. LPAs selected eleven residents’ medication for review and observed medication and medication records to be accurate. LPAs reviewed eleven resident files and four staff files. Staff files did not contain any documentation for hands-on staff training and AAD was unable to provide LPAs with documentation of hands-on staff training conducted; a Deficiency was cited on today’s date. (LIC809-C) On-the-job training documentation also did not include a statement or notation, made by the trainer, of the content covered in the training; a Deficiency was cited on today’s date. LPAs interviewed ten residents and four staff. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.