Routine inspection·January 8, 2024

On 01/08/2024 at 09:05 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. Executive Director David Steinstra and Executive Director Mary Wolfe arrived at the facility during the visit. At the time of the visit there were one hundred thirty-eight (138) residents present. The facility is a residential care for the elderly (RCFE) Continuing Care Retirement Community (CCRC). The facility is licensed for a capacity of two hundred ninety-seven (297) of which eighty-two (82) Ambulatory and two hundred fifteen (215) non-Ambulatory and five (5) Hospice Waiver residents. Also, the facility’s approved for delayed egress and approved for secured perimeter. LPA Brown was accompanied by Memory Care and Assisted Living Director Denise Perez to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 112 degrees F. The facility is equipped with operating smoke detectors however, LPA Brown observed no carbon monoxide alarms throughout the facility. Deficiency will be issued. The facility purchased the required carbon monoxide alarms during the visit on 01/08/2024 and installed it throughout the hallway of the facility. Moreover, fire extinguishers were also observed at the facility. Posters such as personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C *** Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Room with the resident’s medications locked. LPA Brown observed complete first aid kit and first aid book at the facility. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than three (3) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. All kitchen staff have their updated ServSafe Cerification and food handlers card. Care & Supervision: The facility has an Executive Director David Steinstra present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA Brown reviewed fourteen (14) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Brown observed that Resident #2(R2) and Resident #14 (R14) don't have their Admission Agreement in their facility file. Technical Violation Issued. Memory Care and Assisted Living Director Perez reprinted R2 and R14 Admission Agreement and kept it in their facility file during the visit on o1/08/2024. LPA Brown reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA Brown observed files reviewed were complete except for Staff #1 Administrator Certification expired and no renewal packet submitted for processing. During the visit on 01/08/2024. Deficiency will be issued. S1 mailed the renewal packet for processing. Medications/Medication Administration Record (MAR) were audited during the visit on 01/08/2024, and LPA Brown observed no issue. Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), LIC809D, LIC9102 forms, and Appeal Rights were discussed and provided to Memory Care and Assisted Living Director Denise Perez.