Routine inspection·January 22, 2025

Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection at the facility. The LPA was allowed entrance into the facility and met with Executive Director (ED), Brooke Abrego-Huerta, and informed her of the purpose for the visit. The inspection included the following: Infection Control Plan: The facility has an Infection Control Plan in place. The plan does not appear to be reviewed annually, as documentation shows it was last reviewed on 05/04/2022. According to the ED, the facility is following the policies listed in the plan whenever there are infectious outbreaks within the facility. Operational Requirements: The facility does have a Plan of Operation available at the facility, which includes a Dementia Plan of Care and Bedridden Plan of Care. Proof of liability insurance was observed on file and expires on 06/01/2025. Personnel Records-Training: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Training on dementia care, postural supports, restricted health conditions, hospice and medication administration was observed on file; though incomplete. Postural support training, which is a required 4 hours, was not completed for four (4) care staff members. An advisory notice will be issued. Resident Rights-Information: The facility has internet accessible devices available for resident use. The LPA did not observe the complaint poster (PUB 475), non-discrimination notice, Personal Rights (87468.1) or Personal Rights of Residents in All Facilities (87468.2) to be posted. An advisory notice will be issued. Disaster Preparedness: The facility does have an emergency and disaster plan in place, which included contact information for appropriate agencies. Proof of staff training on emergency procedures was observed on file. Proof of emergency drills were observed on file; a Fire Drill was completed with staff and residents on 01/17/25. Due to insufficient time a follow up visit will have to be conducted to complete the inspection. This report was reviewed with ED Abrego-Huerta and a copy was provided.