Routine inspection·May 13, 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 Executive DIrector (ED) Bryan Reamer-Yu and Crystal Vital, Resident Care Director (RCD) and explained the purpose of the visit. Bryan Reamer-Yu has an Administrator certificate with expiration date of August 25, 2024 . The facility is licensed to provide services to residents age range 60 and over, (139) Non-ambulatory, of which 10 may be bedridden. Approved for delayed egress, and has a hospice waiver for (10) ten residents. There are currently two (2) residents receiving hospice care services. Between 9:25am-1:00pm, LPAs reviewed ten (10) resident files and ten (10) personnel files. LPAs along with (ED) Bryan Reamer-Yu and (RCD) Crystal Vital toured the interior and exterior of facility premises including memory care and Assisted Living area. 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 resident bathrooms which ranged between 118.0 degrees- 118.7 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. All linens and furnishings were clean and in good repair. Smoke alarms and carbon monoxide detectors were last serviced on 4/9/2024. 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. PPE stored in storage room located in the second floor area. CONTINUED ON LIC 809-C PAGE.... CONTINUED...While conducting facility inspection and resident interviews, LPAs pulled chord in Resident 7(R7) bedroom area at 2:51pm. At 2:58pm, LPAs inquired about call light response system to R7's bedroom area, ED Reamer-Yu verified no response indicating there was a system in place alerting staff of call light pendants. At 2:58pm, LPAs observed call light for Resident 11 (R11) had been pressed at 2:14pm with no response time. LPAs interviewed R11 who indicated "I pressed the call light 40 minutes ago and no one came by, my wife went to go look for someone but no one came and I wanted to go to bible study." This was verified with ED Reamer-Yu present. (SEE LIC 809-D) LPAs observed staff answer facility telephone which verified a working telephone was maintained at the facility. Regulatory required postings were observed in multiple places throughout the facility. The Facility was operating within the allowed capacity. Fire extinguishers were charged, mounted throughout the facility and last serviced 7/12/2023. Facility indicated Pest Control services facility monthly, last serviced on 4/10/2024. LPAs verified that fire/disaster drills are conducted monthly and on each shift. Last fire drill was conducted on 4/10/2024. The Emergency exit plans were posted and available for reference throughout the facility. Residents were accorded clean and comfortable accommodations. LPAs observed Laundry area on all floors with funcitonal and operational washers and dryers. Based on the observations made during today’s visit, the facility is being cited per Title 22, Division 6, of California Code or Regulations. An exit interview was conducted with ED Bryan Reamer-Yu. A copy of today's report, LIC 809-D, Appeal rights and LIC 858 and LIC 859 pages were provided at exit.