Routine inspection·December 2, 2022

On 12/2/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a one year annual inspection. LPA Jensen met with Executive Director Diane Wright and explained the purpose of today's visit. The facility is a two story building with a single designated entrance. There are infection control and COVID screening signs posted at the entrance and throughout the building. At the front hall reception desk there is an electronic sign in and screening system that generates a visitor tag. All staff were observed to be wearing masks. The facility maintains an adequate supply of PPE. The facility was observed to be sanitary and free of odor. LPA Jensen toured the kitchen, the dining hall, 2 activity rooms, the laundry rooms, main hall bathrooms, guest suites, medication room and grounds. The grounds were observed to be well maintained and all paths were free of obstruction. The window screens were all observed to be in good repair. The fire extinguishers were last serviced in September of 2022 and are in compliance. The kitchen was observed to be sanitary. There was a menu posted and lunch service was observed. The lunch served was consistent with the menu that was posted. The kitchen is separated from the dining hall and only employees have access to the kitchen. First aid kits were maintained and observed to be complete. Toxins and cleaning supplies were observed to be stored away from all food products. The ice machine was observed to be sanitary. LPA Jensen observed in excess of a 7 day supply of non-perishable food and a 2 day supply of non-perishable food. LPA Jensen toured 4 resident suites. The suites were observed to be adequately furnished and lit. 2 of 4 resident suites observed had portable heater units. 2 of 4 suites observed had an air conditioning unit in the window that was not properly sealed allowing for air flow from outside. Continued on LIC 809C.... The portable heaters do not have a mechanism to set the unit to specific temperature. LPA Jensen interviewed resident 1 (R1) and resident 2 (R2) with portable heaters in their room and R1 and R2 both indicated they have to constantly turn the heaters on and off in an attempt to adjust the temperature. 1 of 4 resident rooms had an HVAC system that had a broken fan creating a constant noise. LPA Jensen tested the call alert system in the room of R1 at 11:14am, LPA Jensen waited 20 minutes and there was no response by staff. LPA Jensen tested the call alert system in the room R3 at 10:34, LPA Jensen waited 12 minutes and there was no response by staff. Water temperature in resident suites was measured at 116 degrees which falls within the required regulatory range of 105-120 degrees. LPA Jensen observed the medication room to be organized and observed medications to be locked in med carts. The narcotics were locked separately. LPA Jensen conducted an audit of the narcotics in collaboration with Staff 1 (S1) and found the documentation and medication count to be in order. LPA Jensen observed an extensive activities program to be offered including but not limited to Holiday shopping, holiday dress up days, Christmas caroling, spiritual services, gift exchanges, shopping excursions, resident socials and service animal visitation dates. LPA Jensen reviewed 3 resident files and 2 staff files. The facility is in the process of conducting file audits and reorganizing staff and resident files to stream line and ensure all necessary documentation is easily accessible. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result result in civil penalties. An exit interview was conducted and a copy of this report and appeal rights was given.