Routine inspection·May 8, 2024

On 5/8/2024, Licensing Program Analyst’s (LPA’s) Jenifer Tirre, Kimberly Lyman and Edward Kim conducted an unannounced required visit using the CARE Inspection Tool. LPA’s were greeted by staff and granted entry after stating the purpose of the visit. Administrator (Admin) Erin Rehbein was present to assist with the facility inspection on today's date. The facility is licensed for (144) non-ambulatory residents with approved hospice waiver for ten (10) residents. Currently, there are three (3) Hospice residents present during today’s visit. At around 9:00am , LPA’s conducted a tour of the physical plant accompanied by Administrator Erin Rebehin, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. LPA’s observed one bedroom room 119 to have missing smoke detector. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured between 105.1 to 117.6 degrees F. A comfortable temperature of 76 degrees F. was maintained in the facility. LPA’s observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. During visit five fire extinguishers were observed as fully charged and mounted. A review of the Medication Records Administration (MAR) was conducted, and LPA’s observed the records are in compliance. A review of staff and resident records were reviewed and observed to be out of compliance. CONTINUED ON 809C During the visit, LPA's observed the facility's infection control practices. LPA's observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA's observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA’s observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 4/4/24. The facility provided documentation from Cal Fire which confirmed operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 8/1/2023- 8/1/2024. A review of ten residents (R1-R10) service files was revealed to be complete. Ten staff files were reviewed (S1-S10) and ten out of ten personnel files revealed to be incomplete in area training. Based on the observations made during today's visit, deficiencies are being cited as per the Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator.