Routine inspection·February 15, 2023

Unannounced annual visit conducted on 02/15/2023 by Licensing Program Analysts (LPAs) Charlie Yang and Kimberly Viarella who requested that the facility designated administrator, Sheryl Bravo, be notified that CCL was present at this time. Brief interview conducted with the facility designated Administrator. It was learned that there 6 hospice residents with 11 in memory care and 2 residents receiving home health. Current census was 54 residents. LPAs toured the facility grounds and observed the following. The dining room and common areas in the buildings were found to have adequate furniture and lighting. There were no trip hazards observed at this time. The kitchen area was inspected and found to be clean with refrigerators and freezers observed to be at the required temperatures. There was an adequate 2 day perishable and 7 day non-perishable food supply observed at this time. Residents do not have access to the kitchen and it is locked when it is not being staffed by the chef and kitchen employees, thus ensuring that sharp knives and other kitchen implements were made inaccessible at all times. A sample of the resident bedrooms were toured and observed to be in order with adequate furniture and lighting. Brief interviews were conducted with the residents. Resident restrooms were toured. The hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees at all times. Grab bars were observed to present and in functional order at this time. Non skid mats were also oberved to be present and in good order at this time. LPAs toured the Medication Room. It was a separate locked room adjacent to the main lobby. Each of the Med Techs on shift have access to the room, its paper logs, and the computerized EMAR system. The medication cabinet for narcotics had a double lock system. Medications were distributed to each resident individually and logged at the point of consumption. While touring the exterior grounds of the facility, LPAs observed a new fence bordering the memory care unit had been installed. A review of the facility perimeter fence, side gates, and exits was conducted. Fire extinguishers, hung throughout this facility, were reviewed to make sure that they were annually inspected and in compliance at this time. The following forms and documents were requested to be updated and submitted into CCL for review by this LPA: LIC 308 LIC 400 LIC 500 LIC 610 The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code. The appeal rights were printed and a copy was given to the facility designated Administrator Sheryl Bravo at this time. Exit Interview