Routine inspection·April 3, 2025

Licensing Program Analyst (LPA) Michelle Echeverria made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator, Wendy Barrera and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) licensed capacity for (130) nonambulatory of which (130) can also be bedridden, hospice waiver for (20). The facility has (54) resident bedrooms with private bathrooms in the assisted living wing and (29) resident bedrooms with shared bathrooms in the memory care wing. The facility also has additional resident and staff bathrooms, offices, reception area, club house, wellness room, library, activity room, entertainment rooms, kitchen, dining area, (3) laundry rooms, staff room, medication room, and shaded patios. LPA was accompanied by Wendy 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 comfortable temperatures 74, 71, 70, 72, and 73 degrees fahrenheit. Water temperatures measured at 122, 119, and 115 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating fire extinguishers, smoke detectors, sprinklers, signal alarms and carbon monoxide alarms. Posters such as personal rights, CCL complaint poster, CCL license, ombudsman, and resident rights were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for residents/staff files. Medications were kept inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Pesticides and other toxin's are not stored in food areas. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed residents files for admission agreements, physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed (5) personnel reports missing from the staff files. Deficiency issued. LPA reviewed facility's file for emergency drills, emergency disaster plan, annual fire inspection, infection control plan and insurance policy. LPA observed the infection control plan not reviewed since 04/18/22. Technical violation issue. One deficiency and one technical violation was cited during this visit. An exit interview was conducted, this report LIC809, LIC809C, LIC809D and appeal rights were discussed and provided to Administrator, Wendy Barrera.