Routine inspection·August 14, 2025

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit. LPA Moleski reviewed five resident files (R1-R5) and five staff files (S1-S5). LPA Moleski reviewed R1's file. R1's LIC 602 was dated 6/21/25. R1's move-in date was recorded as 7/28/25. R1's LIC 602 indicated that R1 had a pressure injury, but it was not staged. R1's LIC 602 indicated that R1 did not have home health services. In an interview, the facility's health services director (S6) said that they were not aware R1 had a pressure injury upon admission. An assessment for R1 dated 7/27/25 indicated that R1 did not have any wounds or bedsores. Dial said he received R1's LIC 602 from R1's previous placement on 7/25/25. LPA Moleski reviewed ongoing notes for R1. An "open area" was identified on R1's heel on 7/29/25, according to a note written on that same date. On 8/3/25, a "worsening condition of wound on left heel" was noted. The "top skin layer came off," and was "oozing and bleeding," according to the note. An incident report from 8/3/25 indicated that R1 was sent to the hospital, and S6 "started the process of obtaining a referral for home health" on that date. S6 said that R1 received no wound care at the facility prior to 8/7/25, when home health personnel visited for the first time. S6 said that they would have been able to secure a referral for home health prior to R1's admission if they were aware that R1 had a wound. [continued on 809-C] LPA Moleski reviewed R5's file and observed an LIC 602 dated 2/9/2022, and a second LIC 602 dated 8/1/2023. LPA Moleski asked for documentation of a routine annual visit within the last year. LPA Moleski was provided after-visit summaries for R5 from emergency room visits in December 2024 and April 2025 for confusion resulting from a UTI and a fall, respectively. Neither of these constitute routine annual visits evaluating general health. LPA Moleski toured the facility with Dial and inspected common areas, kitchen areas, bedrooms, bathrooms, and outdoor areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 109 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. During LPA Moleski's tour, LPA Moleski and Dial observed a bottle of degreaser left unattended outside. LPA Moleski and Dial also observed that the facility maintenance director's office was unlocked. The office, which has a primary entryway leading from the common outdoor area, contained multiple cleaning solutions and potentially hazardous tools. In two separate memory care cottages, LPA Moleski and Dial observed lime scale remover and isopropyl alcohol left in unlocked cabinets, respectively. LPA Moleski and Dial observed on the floor of a memory care cottage medication room one tablet of medication and one half of a medication capsule shell. LPA Moleski observed first aid supplies, fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed locked carts used for the storage of medication. LPA Moleski interviewed two staff members (S7-S8) and three residents (R4, R6-R7). This facility is hereby cited per 22 CCR Sections 87631(a)(1), 87309(a), 87465(h)(5), and 87463(h)(1). An exit interview was held with Dial. Appeal rights and a copy of this report were left with Dial.