Routine inspection·August 29, 2024

*Amended report* 08/29/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA met with Terri Harris, Concierge, where LPA explained the purpose of the visit. The facility is licensed to serve residents age range 60 and over, 110 non ambulatory, of which 12 may be bedridden. The facility has an approved hospice waiver for 20, and for delayed egress. There are 13 residents receiving hospice services. The facility consists of (6) single story cottages with fifteen bedroom/bathroom units in each cottage. There is a total of (4) cottages dedicated to assisted living residents and (2) cottages dedicated for memory care residents. Below is a summary of what was observed during today's visit: LPA conducted a tour of the interior and exterior areas of the facility, there are no pools or bodies of water on the premises. LPA conducted a review of both staff and record files. LPA reviewed (6) resident files that were observed to have the required documents such as medical assessment, needs and services appraisal. Regarding staff files, all staff present at the facility were observed to have obtained criminal record clearance, and to be associated to the facility however, there was no proof of valid CPR certification in the (6) files reviewed deficiency cited. The staff files reviewed were not observed to have any updated required training. In addition LPA observed for the facility to have a change of administrator. LPA discussed that a request should be submitted for the facility administrator to be updated with the regional office. The kitchen which is in the main building was observed to be clean, and clutter free. There was plenty of cookware, dishes and utensils to serve the residents in care. The facility was observed to have a 2 day supply of perishable and a 7 day supply of non perishable food items. All meals are prepared in the kitchen and delivered to each cottage. Each cottage has an dining room, which consists of a kitchenette that was observed to have food warmers, refrigerators, and pantry. The resident bedrooms were observed to be clean and odor free, the cottages were at a comfortable temperature. The hot water was tested and found to be within regulatory limits measuring 105.4-114.2 degrees Fahrenheit. The medications are locked inside medication carts. The facility uses electronic Medication Authorization Records (MAR)s. Each cottage was observed to have a fully charged fire extinguisher. The smoke and carbon monoxide detectors were unable to be tested at the time of LPAs visit as there was not a staff on grounds that knew how to test the devices. LPA conducted a review of the fire inspections log and observed that there is no record that the facility has been conducting emergency disaster drills on a quarterly basis. The last drill documented was an elopement drill that was conducted on 5/19/22. deficiency cited. Based on today's inspection citations were issued on the attached 809D in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted and a copy of this report, 809D, appeal rights, and LIC9098-Proof of Corrections form was reviewed and provided to Terri Harris.