Routine inspection·January 29, 2024

Licensing Program Analyst ( LPA) Magda Malcore made an unannounced visit to the facil ity to conduct a required annual inspection. LPA met with Nancy Thrane, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (10) and a current census of (9) residents in care. The facility has a hospice waiver for (2) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. Outdoor shaded area is sufficient for resident activities; however the facility does not have an entirely enclosed outdoor leisure space and is currently providing care for persons with Dementia. Deficiency cited. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s bathrooms were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured 106 degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. Facility has carbon monoxide detectors and telephone service. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, theft and loss policy, "oxygen in use" signs, and emergency telephone numbers. Care & Supervision : Facility has 24-hour care staff. Staff working have criminal record clearances or exemptions through the Department. Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Sharps, pesticides and other cleaning solutions were kept locked and stored away from food areas. Record Review: Review of (4) staff files reveal, the facility did not maintain record of staff #1 (S1) and staff #2 (S2) required job training on file. Deficiency cited. (4) resident files reviewed were observed to be complete. The last fire safety drill was conducted on 12/13/23. Administrator’s certification expires on 2/9/2024. Facility's liability insurance expires on 4/22/24. Medical Related Services : All medication is centrally stored and kept locked in medication room. Based on observations and record review, deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. An exit interview was conducted where the licensing reports were discussed and copies with Appeal Rights were provided to the Administrator at the conclusion of the visit.