Routine inspection·October 23, 2024

On 10/23/24, at 10:15am, Licensing Program Analyst (LPA) Arvin Villanueva, arrived to this facility unannounced to conduct their required annual inspection visit. LPA met with Susan McClure, Assistant Administrator (AD), and explained the purpose of the visit. The facility currently has an approval to retain/accept 144 non-ambulatory residents, 10 of which may be bedridden residents. LPA and AD toured the facility to ensure compliance of Title 22 regulation. Facility is a two-story building located in a residential neighborhood. LPA observed the first floor, second floor, the activity room, dining room, elevator, stairwells and random resident apartments/units. Facility has a 144-resident capacity for both assisted living and memory care residents. Memory care area is located on the first floor. Facility has one elevator and currently operable and in good repair during this visit. Facility has 3 stairwells. Each stairwell were equipped with evacuation sling located in the second floor for emergency use. 1 of 3 stairwell is equipped with evacuation chair located at the first floor of the stairwell. LPA observed 5 of 6 fire extinguishers to be expired and were last serviced on 10/4/23. The resident apartments/units are spacious enough to accommodate the residents' furnishings. 6 of 6 resident apartments/units were observed. Each resident apartment/unit is equipped with resident bathroom, small refrigerator, and air conditioning/heating unit. The air conditioning/heating unit are operated by the residents. Each apartment/unit is equipped with sprinkler system. 6 of 6 resident bathrooms were observed. Water temperature in 6 randomly selected bathrooms (in a resident apartment/units) were measured at between 110 and 114 degrees F. In one resident bathroom (R1), their hot water sink faucet did not have hot water. In one resident bathroom, it did not have a grab bar by the toilet for non-ambulatory resident. Technical Advisory (TA) was provided to AD to clean out cobwebs observed at the ceiling in resident apartment/units. TA was also provided for facility to conduct minor repairs such as drawer in disrepair observed in one resident apartment/unit and medicine cabinet in disrepair in another resident apartment/unit. Photos were taken for reference. {1 of 2} LPA observed a shaded area in the courtyard with tables and chairs. Additionally the outdoor area for activities is secure for dementia residents. Outdoor passageways, walkways, driveways, and steps are free from obstructions and hazards. The facility does not have bodies of water at this time. LPA and AD inspected the kitchen and main dining area. Kitchen was observed to be clean and sanitized. Food were observed to be properly stored during this visit. Facility kitchen has 5 freezers, 2 refrigerators and 2 pantries for dry and canned foods. Main dining room was observed to be clean and sanitized. This is also where the fireplace is located and it was observed to be enclosed. The medication room is located in the first floor and medications were observed to be properly stored, locked and inaccessible to residents in care. LPA conducted file review of 6 resident files and 8 staff files. LPA was unable to review facility's infection control plan and Emergency Procedure Plan at this time. Per interview with the Business Office Manager, they have not conducted quarterly drills since COVID. The following deficiency was observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Failure to correct the deficiency may result in civil penalties. An exit interview was conducted with AD, and a copy of this report and appeal rights were provided. {2 of 2}