Routine inspection·July 28, 2021

On 7-28-21 at 9:30am Licensing Program Analysts (LPA)s Tirzah Hubbard and Charlie Yang conducted an unannounced Annual visit. LPAs met with Mary Ann, Health and Wellness Coordinator, and Susie Sarrie, Business Officer Manager, to discuss the purpose of the visit. Census: 48 Staff Census: 10 Mitigation plan has been received during visit on 7-28-21. LPAs observed 2 hospice, 3 bedridden with bedridden clearance for Brook Dale Elk grove location. LPAs have requested updated Bedridden and Hospice clearance documents by 7-30-21 for Pegasus Elkgrove. LPAs have received hospice and bedridden documents for Brookdale location.. LPAs observed all Caregivers with Finger print clearance. LPAs toured physical plant of facility. The facility contained 6 cottages total with two memory care. LPAs observed the memory Cottage in compliance. LPAs observed medication logged into MARS up to date in memory care cottage. LPAs met with S1 to discuss medication log in and schedule. LPAs observed medication not logged properly Cottage 1, 2, and 3. MARS contained incorrect log in dates and medication administration. LPAs met with S2 Medication Aide for cottage 1, 2 and 3 to discuss the medication guidelines for logging into MARS. LPAs observed cob webs and bugs located around the doors of each cottage of the facility. LPAs observed each cottage containing dirt and stains located on each carpet of the cottages needing cleaning and replacement. LPAs observed each window of the facility needing cleaning. Thermostat: 70 degrees LPAs requested documents to be submitted for file review: LIC 500 LIC308 LIC 400 LIC 610 The hot water was measured at 116 *F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPAs Tirzah Hubbard observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. LPAs observed the smoke detector located in the kitchen in disrepair and detached from ceiling. LPAs observed food supplies of staple nonperishable foods. There were perishable foods for a minimum of two days that shall be maintained on the premises at all times. The kitchen staff left food unattended and un covered to take a phone call on 7-28-21. The Kitchen manager covered the food and spoke to the kitchen staff for leaving food uncovered. The sharp objects that are : Knives, forks, and spoons were locked away. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed and cited on LIC809 D. Exit interview held, copy of report given on 8-15-21 return visit. Appeal rights printed.