Routine inspection·July 31, 2024

Licensing Program Analysts (LPAs), Seo Jeon and Javina George made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPAs were greeted and granted entry to conduct the inspection. On today’s visit the LPAs met with administrator, Eloiza Castellanos and she was notified of the purpose for the visit. This facility is 2 story building with 148 apartment units, (40 units in memory care and 108 units on the assisted living side). This facility currently has 148 residents including 11 receiving hospice services, 31 dementia, 26 home health, 15 receiving oxygen administration and no bedridden. This facility has maintenance staffs who are in charge of regular cleaning and maintenance. LPA reviewed the facility's infection control plan and found all required infection control measures. There is a separate room Personal Protective Equipment (PPE) supplies. LPA observed a full service restaurant, movie theater, library, game room, art room, pool table, gym and several lounges. Physical plant, floors, windows, and doors were observed to be clean and in good repair. Fixtures and furniture were in good repair and were present. The outdoor area was observed to have lots of shaded area for clients and was free of hazards. This facility has fenced/gated swimming pool. Cleaning chemicals are all handled by the maintenance staffs. LPA was informed that there is a team of maintenance staffs. The hot water temperature was recorded at 109.9 in room# 107 and 114.0 degrees F in public restroom. All units are apartments with with kitchen, bathroom and bedrooms. Residents can either dine at the restaurants or receive food services from the facility. Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff schedule showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The administrator Eloiza Castelleanos does not possess a valid administrator's certificate as it expired on 7-14-2024. Deficiency cited . Per Eloiza there are still CEUs that need to be completed. In addition a change of Administrator request was submitted in January 2023. However due to there not being a valid administrator certificate, the change of administrator cannot be completed at this time. Once all required documentation is received which includes a valid administrator certificate the change of administrator wiill be made. LPA reviewed eight(8) staff files and training logs. All staffs have criminal clearance and updated training along with CPR/First Aid Certification. Eight(8) client files were reviewed and possessed all required paperwork. Medications are stored in a locked cabinet inside a med room with locked door on the first floor. Computerized medication log is maintained. Medications logs were reviewed and they appear to have been dispensed accurately. LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility performs monthly fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. The smoke and carbon monoxide detectors were tested and observed to be operable. The signal system as also observed to be operable. Fire extinguishers show annual inspection tag. An exit interview was conducted where a copy of this report, LIC809D and appeals right were provided to administrator, Eloiza Castellanos. LPAs left the facility at 12:30 pm and returned at 1:25 pm.