Routine inspection·April 11, 2024

On today’s date, Licensing Program Analysts (LPA) Rosie Quiroz and Rose Ruppert conducted an unannounced visit for the purpose of conducting an annual required evaluation. LPAs were greeted upon entry to the facility by front desk concierge. LPAs met with Health and Wellness Director (HWD) Laura Sanchez and explained the purpose of the visit. Administrator (AD) Justine Ortiz arrrived shortly after. AD Justine Ortiz has an Administrator certificate with expiration date of 11/4/2023. AD Ortiz indicated submitting payment and CEU's and pending renewal. AD Ortiz agreed to submit copy of Administrator certificate to CCLD upon receiving it. The facility is licensed to provide services to residents age range 60 and over, (220) Non-ambulatory, of which 20 may be bedridden. Non Ambulatory on first and second floor and 50 percent of third floor. Approved for delayed egress, and has a hospice waiver for (40) forty residents. There are currently thirty four (34) residents receiving hospice care services. Between 9:55am-11:20am, LPAs reviewed ten (10) resident files and ten (10) personnel files. Six of ten personnel files were missing health screening and Tuberculosis test screenings. (SEE LIC 809-D) LPAs along with AD Justine Ortiz and Maintenance Director Alfonso Cerda toured the interior and exterior of facility premises. The required two (2) day perishable and seven (7) day non-perishable food supply was observed. Toxic substances were locked and inaccessible to residents. LPAs observed cooking areas to be maintained with cleanliness. LPAs observed facility refrigerator and freezer to be operational and met regulatory requirements. Resident bathrooms were observed to have working sinks, faucets and flushing toilets. LPAs tested hot water temperatures in seven (7) resident bathrooms which ranged between 113.0 degrees- 120.2 degrees Fahrenheit. Grab bars and non-skid mats were also observed in resident bathrooms. Personal hygiene items for resident use were observed in each bathroom. LPAs observed all resident rooms to have required linens, furnishings, and adequate lighting. (CONTINUED ON LIC 809 C) CONTINUED...All linens and furnishings were clean and in good repair. Smoke alarms and carbon monoxide detectors were last serviced on 2/15/2023 by Tricom Fire and Electric Company. The medications were inaccessible to residents, centrally stored and maintained in compliance. All pathways, doorways, and emergency exits were observed to be free of obstruction. There were no bodies of water observed anywhere on the property. Emergency lights for use in the event of a power outage are stored in medication room area. PPE stored in Building #2, second floor area. LPAs observed staff answer facility telephone which verified a working telephone was maintained at the facility. Regulatory required postings were observed in the resident mail box area of the facility. Facility was operating within the allowed capacity. Fire extinguishers were charged, mounted throughout the facility and last serviced 7/11/2023. Facility indicated Pest Control services facility two times per month, last serviced on 3/29/2024. LPAs verified that fire/disaster drills are conducted at least quarterly and on each shift. Last fire drill was conducted on 2/8/2024. The Emergency exit plans were posted and available for reference throughout the facility. Residents were accorded clean and comfortable accommodations. Based on the observations made during today’s visit, the facility cited per Title 22, Division 6, of the California Code or Regulations. An exit interview was conducted with ED Justine Ortiz. A copy of today's report, LIC 809-D, Appeal rights and LIC 858 and LIC 859 pages were provided at exit.