Routine inspection·December 10, 2024

On December 10, 2024 Licensing Program Analyst (LPA) Murial Han conduct an annual inspection. LPA met with Community Business Director, Seema Chand and explained the purpose of today's visit. The Community Business Director and the Maintenance Director provided a tour of the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 6 floor facility; 1st floor being the entrance to the lobby, 2nd floor for Life Guidance (LG) residents and common areas, 3rd-6th for Assisted Living (AL) and Independent Living (IL). All floors have elevators and laundry services. Medications are locked in the medication rooms and inaccessible to residents in care. A comfortable temperature is maintained and lighting is sufficient for comfort. Chemicals, toxins, and sharps objects were locked and inaccessible to residents. 2 days of perishables and 7 days of nonperishable foods were observed for the residents. Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguishers were last serviced on 11/24/2024. Emergency drill records observed to be sufficient. Hot water temperature through-out the facility was measured at 106- 118 degrees F. During the medication review, LPA interviewed med tech (S1) regarding to the facility’s medication destruction process and the participants. He/she stated that the facility would complete the Medication Destruction Record and if it was non-Narcotic medication, it would be witnessed by a designated staff and another adult who was not a resident and if it was narcotics, it would be the administrator and the resident service director. According to the documentation provided by the facility, LPA observed the medication destruction records (both non-Narcotic and Narcotic Medications) for resident #1 (R1) did not have the administrator’s signature on it. In addition, the med tech confirmed that the signatures on the records were not the administrator. During the tour, at 10:20am in the Life Guidance Unit (Memory Care Unit), LPA observed personal grooming and hygiene items were not in resident's own possession as LPA observed a bottle of the Free & Clean hand wash soap bottle in room 209 and 218's shared bathrooms that were labeled for 209B and 218B. A review of (5) resident files was conducted and noted on the LIC 858. A review of (5) staff files was conducted and noted on the LIC 859. The following documents were requested submitted to CCL by 12/18/2024: - Liability Insurance and the administrator certification Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with the Community Business Director. A copy of this report and the appeal rights were provided.