Routine inspection·January 20, 2023

On 1/20/23 at approximately 10:30am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual. LPA Jensen met with general manager Zachary Murphy-Duncan and explained the purpose of today's visit. The facility has two main buildings plus a smaller detached single room structure. There is a swimming pool on the grounds that is fenced and locked and a pond on the grounds that is covered with fencing materials. The grounds were observed to be well maintained and free of debris. There is a large outdoor space for activities and patio furniture available for resident use. The grounds are gated all around. Upon arrival at the facility LPA Jensen was greeted by a care provider who met LPA at the gate, verified her identity and took a temperature reading. LPA Jensen was then escorted to the side of the house where she was provided a face shield and gown and instructed to wash her hands before entering. The facility was observed to be sanitary and free of odor. All sharp objects and toxins were observed to be locked and inaccessible to residents in care. The facility was observed to have a 2 day supply of perishable food and a 7 day supply of non perishable food on hand. A menu was posted in a prominent place in the kitchen. The refrigerator temperature at site 100 was observed to be at approximately 68 degrees. As a result of the refrigerator temperature reading above the required regulatory temperature, facility staff discarded all perishable food in that refrigerator. There was still sufficient food supply on hand to meet regulatory requirements. LPA Jensen toured the resident bedrooms and observed each to be equipped with a dresser, chair, night stand and lamp. LPA Jensen observed the bathrooms to be equipped with grab bars at the toilet and shower. There were non-slip mats observed in the showers. Continued on LIC 809C.... LPA Jensen tested the smoke detectors and carbon monoxide detectors and found them to be in compliance. The fire extinguishers were observed to be incompliance. The facility conducts fire drills bi-annually and the last fire drill was conducted in October of 2022. There is emergency lighting, food, and a 30 day supply of PPE on hand. The facility maintains at least one first aid kit in each building that is complete with scissors, tweezers, thermometer and manual. LPA Jensen observed the emergency disaster plan to be posted and in compliance. The facility has back up generators for use in case of an emergency. LPA Jensen observed all medications to be locked and inaccessible to residents in care. LPA Jensen reviewed a random resident file and staff file and observed them to be complete. The facility has just implemented a log for documenting the effectiveness of PRNs. LPA Jensen observed the liability insurance to be current and was given a copy for the master file. All staff present at the facility were observed to have criminal background clearance and were associated to the facility. The licensing fees were determined to be in arrears. LPA Jensen observed all required signage in the facility including but not limited to resident rights, resident council, Ombudsman contact information, "Say Something, See Something" and COVID infection mitigation. Citations are being issued from the California Code of Regulations. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted a copy of this report was provided.