Routine inspection (multi-day)·June 11, 2024

On 6/11/24, Licensing Program Analyst (LPA) Kimberly Viarella arrived at this facility to continue the annual inspection. LPA identified herself upon arrival, stated the purpose of her visit and asked to meet with the Designated Facility Administrator (DFA). LPA met with Neal Torres and a brief meeting followed. LPA provided materials to assist with future file reviews. LPA then returned to reviewing staff files to ensure proper background clearances, health checks and training were all in compliance. LPA reviewed 4 resident files. All were complete and up-to date at the present time. LPA observed that the DFA's certificate (# 6032067740) expires on 01/02/2025 and was in compliance at the time of the visit. LPA reviewed 3 staff files and found that they were missing annual training. In 2 of 3 files, the files did not contain the required number of annual hours of training and the training did not include the name and credentials of the trainer or the regulations that the training pertained to. 2 out of 3 were Medication Assistants but the training logged and presented did not include annual medication training. 1 of the 3 staff files did not meet the annual training requirements and had repeated course content listed. The DFA produced a binder with in-services that were conducted and signature sheets of attendees, however, these did not meet regulation requirements. The DFA also produced an excel spreadsheet to demonstrate that training was implemented, however, the log sheet did not include the duration of the trainings, the trainer, or specific content. It also did not include the topics required as mandatory for annual training. LPA provided technical assistance and handouts which referred to the regulation requirements in order to assist the DFA in establishing a more efficient system for implementing and tracking required trainings. As part of this annual inspection the LPA visited 2 of the 4 medication rooms at this facility, one in memory care and the main one in assisted living. LPA inspected med carts, checked for expired medications and reviewed dosing, storage, destruction, and PRN procedures with the Medication Assistants in each area. LPA tested the response time for staff on two occasions in different parts of the facility. LPA activated the pull cord in the restroom of a resident in one wing of the facility. Care staff arrived in 13 minutes and 39 seconds. After visiting the medication room, the LPA observed a resident in another wing of the building activate their pendant and care staff arrived in 1 minute and 3 seconds. LPA concluded the inspection of the building by walking the perimeter with the DFA. There were no outbuildings or water features present. The exterior of the facility and the grounds surrounding it were in good repair at the present time. According to California Code of Regulations, Title 22, the following deficiencies were observed during this inspection. They were cited on the LIC 809D page. Civil penalties were also assessed for the missing background check and lack of transfer associations. A copy of this report was provided along with Appeal Rights. Exit interview.