Routine inspection·July 17, 2023

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Executive Director, Maria Arriage, who was informed of the purpose of the visit. At the time of the visit there was seventeen (17) staff and fifty-two (52) residents present. The facility has a dementia program and approval for locked perimeters with an alarm and signal system. The facility does not have any bodies of water and does not allow firearms on premises. The facility is approved for 20 hospice residents; currently the facility has 15 residents receiving hospice services. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following: Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. Physical Plant: LPA observed the resident bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The smoke detector and carbon monoxide was operational, and the hot water temperature 115.9F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Facility receives delivery shipments twice a week and has emergency food prepared. Facility has menus and alternative menus posted for residents. Care & Supervision / Administration: Adequate staff are present for the supervision of residents during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator, possesses a current administrator's certificate. Record Review and Resident/Staff Files: LPA reviewed five (5) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. LPA observed five (5) staff not associated with this facility when looking over staff schedule. LPA informed Executive Director Maria and a civil penalty and plan of correction will be issued. Five (5) resident files were reviewed, and possessed all required paperwork. Health Related Services/ Incidental Medical Services: The facility has a medication room, which is kept locked. The dispensing of residents medications is documented on an electronic MAR log and the medication appears to be locked and stored appropriately. The medication room is stocked with first aid supplies as required by Title 22 regulations. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. An exit interview was conducted where a copy of this report was provided to Executive Director Maria Arriaga.