Routine inspection·October 18, 2024

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by the Concierge. During today’s visit, LPA met with Tana McMillon, Administrator (AD) and LIbbie Retts, RN, MSN, Director of Health Services (DHS). The facility is a two story building with an approved fire clearance of seventy non-ambulatory residents of which twenty-five may be bedridden . The facility is divided into two communities. The first level is the Birch community and the second level is the Peppertree community. The facility currently has a census of thirty-seven residents in care. At 8:40 AM LPA toured the facility and spoke with residents in the dining room after breakfast. Staff members were escorting residents to the common areas and to convert the dining room for residents to have a scheduled fitness activity at 9:30 AM. LPA noted the activity would be a zumba class. LPA inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in four of four resident bathrooms, and testing auditory devices on the delayed egress exits in the Birch neighborhood. The hot water temperature measured between 107.0 and 109.4 degrees Fahrenheit and all smoke detectors were operational and were recently tested by Smart Systems Technologies on October 17, 2024. Fire extinguishers throughout the community were charged and serviced on April 2, 2024. The facility’s last fire drill was conducted on October 3, 2024 by Fire Safety Services, Inc.and are done quarterly. LPA observed one of two elevators were out-of-order but Otis Elevators has conducted an inspection and parts are currently being ordered to repair elevator. (Continued on LIC 809-C) (Continued from LIC 809) LPA inspected the facility food supply with the Director of Culinary Services and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. Dietary modifications are in a binder in the kitchen. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. LPA reviewed five of five staff training and fingerprint records and five of five resident records . LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on March 10, 2025. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Tana McMillon, Administrator and Libbie Retts, RN, MSN, Director of Health Services and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.