Post-licensing visit·May 6, 2024

On 5/6/24, at 10:46am, Licensing Program Analyst (LPA) Arvin Villanueva, arrived to this facility unannounced to conduct their post-licensing visit. LPA met with Alyssa Sellers, current Executive Director (ED), and explained the purpose of the visit. The facility currently has an approval to retain/accept 10 hospice residents and fire cleared to retain/accept 24 bedridden residents. LPA and ED toured the facility to ensure compliance of Title 22 regulation. LPA observed the first floor, second floor, the activity room, dining room, cinema room, elevator, and random resident apartments/units. Facility has a 160-resident capacity for both assisted living and memory care residents. Currently, there are 90 residents in care, including the 17 residents living in the memory care area. Facility is a two-story building. Memory care is located on the first floor. Each floor has medication room and medications were observed to be properly stored, locked and inaccessible to residents in care. The resident apartments/units are spacious enough to accommodate the residents' furnishings. 4 of 4 resident apartments/units were observed to be clean, sanitary and free of obstruction. Each bedroom in the memory care was observed to have an electronic monitoring system installed at the ceiling to monitor resident falls. Per interview with ED, the system detects when a resident falls and notify the care staff. Memory care has delayed egress doors. LPA observed a shaded area in the yard 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. Water temperature in 2 randomly selected bathroom (in a resident apartment/units) were measured at between 105 and 120 degrees F. Room temperature in 4 random resident apartments/units were observed between 70 and 75 degrees F. During the visit, the facility staff conducted a fire drill and the alarms were found to be operable. Con't to LIC809-C LPA conducted file review of 10 resident files and 10 staff files. During resident file review, it was determined that 4 of the 10 residents were diagnosed with dementia. Further review indicated that of the 4 residents with dementia, 3 of which did not have updated physician report and needs and services plan. Per interview with ED confirmed that these required documents were not updated annually as per regulation for the care of persons with dementia. 10 of 10 staff files reviewed were in compliance with Title 22 regulation. LPA obtained a copy of their current resident roster, staff roster and staff schedule. 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 Alyssa Sellers, ED, and a copy of this report and appeal rights were provided.