Routine inspection·December 23, 2024

On this day Licensing Program Analysts (LPAs) Fred Arias and Andrea Mendivil made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 88 non-ambulatory residents of which 10 may be bedridden. Facility has an approved hospice waiver for 15 residents and the facility currently has 67 residents, with 7 residents on hospice. Maintanance Director (MD) Pedro Ucros and Assistant Administrator (AAD) Haley Gmach arrived shortly to conduct facility tour. AAD Gmach has a valid certificate that expires on 8/10/2025. AAD provided updated liability insurance that expires on 7/01/2025. LPAs along with MD Ucros toured the facility at 8:30 AM with AAD Gmach joining shortly after. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 118.6 degrees F and 119.8 degrees F in checked restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPAs toured the kitchen on the first floor in memory care and observed sharps in a cabinet that was not locked. Continued on LIC 809-C dated 12/23/2024. The first floor kitchen in memory care also had toxins under the sink that were not secured due to malfunctioning cabinet doors. MD stated cabinet doors would be replaced and secured during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Some perishable food in the assisted living area kitchen was expired including milk, salad dressing, beef, and fish. Pork patties were observed to be on a kitchen counter kept at room temperature. Smoke detectors are tested quarterly by an outside party with the latest test recorded on 4/17/2024. Fire extinguishers were fully charged. LPAs reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility last conducted emergency drills on 7/31/2024. Outside grounds were toured. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise, arts and crafts, and group movie watching. There is shaded outdoor seating for residents. LPAs observed the emergency food and water supply. LPAs reviewed three resident files, three staff files, and ADD file. All resident files reviewed contained required documentation including admission agreements, physician reports, and resident appraisals. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. Medications are stored in a locked office on each floor. Medications are being administered per physician order. Based on the observations made during today’s visit, 2 deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.