Routine inspection·June 20, 2024

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by receptionist. LPA met with Gerry Vadnais, Senior Executive Director and LPA explained the nature of the visit. Facility is licensed for 115 ambulatory, 174 non-ambulatory residents, of which 16 may be bedridden. Facility has an approved hospice waiver for 20 residents. The facility currently has 103 residents and four residents are on hospice during today's visit. LPA Martinez along with Senior Executive Director toured the inside and outside of the physical plant of the facility. LPA observed a bistro on the first floor where residents can obtain different snacks and beverages selections than in the main dining area. The bistro offers snacks all day so residents may dine when convenient. LPA observed menus for both areas and the food offered is varied and healthful. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Maintenance records were observed in the main kitchen. During the tour LPA observed residents involved in an activity as well as a posted activity schedule including games, exercise, and outings at the facility. LPA inspected that medication is centrally stored in a safe locked location; facility has a medication room. LPA observed and inspected medication carts that are used to dispense meds to residents and observed medication was labeled and stored inaccessible to residents in care. LPA reviewed eleven resident files, all resident files contained required documentation including updated physician reports and care plans. Facility has apartment style bedroom for residents. LPA inspected apartments; all required components were observed in inspected apartments. Each apartment has their own bathroom, LPA inspected resident bathrooms. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Resident bathrooms were tested for hot water temperature and water temperature measured between 118.2 -120.2 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies Continued on LIC809-C were adequately stocked. LPA observed the restrooms are equipped with a call button. Call button when pulled calls to caregiver pager as well as the front desk for response accuracy. LPA observe caregiver receive a call button notification and response time was immediate. LPA observed several residents throughout the facility who appeared clean, and happy. LPA observed several courtyards with shaded seating areas for residents’ enjoyment. LPA observed a swimming pool with a fence around it. LPA observed the pool gate has a self-latching entry door which opens towards the pool. The fence has a key lock at the gate door for inaccessibility. LPA measured the pool fence which measured 6.08ft from base of the floor to the top of the fence and it was observed to enclose the entire pool area. LPA observed the pool has five entry doors throughout the pool area. Toxic chemicals, cleaning solutions and disinfectants are stored locked in the housekeeping storage closet. Carbon monoxide detectors tested and noted to be operational. LPA observed fire extinguishers throughout the facility that are fully charged and had a service date of March 16, 2024. Smoke detectors and sprinkler system are tested yearly by an outside agency, and LPA was provided with testing documentation, last testing was done April 3-5, 2024. Emergency drills are being conducted monthly with a variation of shifts and the last drill conducted on May 14, 2024, which conducted a drill in the AM shift and PM shift. Facility has ten stairwells and ten evacuation chairs in those stairwells. LPA reviewed five staff files. Staff files contained required documentation including health screens, first aid, and fingerprint clearance. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Senior Executive Director and a copy of this report was provided to the facility.