Routine inspection·October 23, 2024

On 10/23/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility above to conduct an unscheduled, required inspection evaluation visit. When the LPA arrived, they were greeted by Senior Director of Health Services Therese Brown. LPA informed facility representatives of the reason for the visit upon entry. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE) Continuing Care Retirement Community (CCRC). This facility is approved for a maximum capacity of three hundred and sixty (360) residents. Of these residents, one hundred and forty-four (144) may be non-ambulatory. The facility has an approved hospice care waiver for six (6) residents in care. The facility is approved for delayed egress entry and exit in the memory care unit of the facility. The LPA inspected the food service areas in the facility including two (2) main kitchens for residents of the facility in the main dining room building. There are also individual kitchen areas in the memory care unit of the facility and the assisted living area of the facility. The facility additionally has a kitchen in the “Grill” building which serves as a more casual dining experience for residents. LPA observed that knives/sharp instruments are stored in locked drawers inaccessible to residents. All appliances were in operable condition and looked clean/in good repair. Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly. Food utensils, dishes, glasses, etc. are clean and in good repair with no cracks or chips. Furniture is room/resident appropriate, clean and in good repair. All rooms are appropriately furnished for their intended use such as bedrooms, dining rooms, kitchens, living rooms, etc. Hot water temperature is maintained between 105-120 degrees Fahrenheit as per Community Care Licensing (CCL) Title 22 regulations. Outdoor activity spaces have shaded areas and furnished for outdoor use. Each resident has an adult bed with a mattress, pad, bedsprings, and pillow, which are clean and in good repair. Each bed is fitted with sheets, pillowcase, blankets, and bedspread that are clean and in good repair. Continued on 809-C Each resident has adequate dresser and closet space for clothing and other belongings that includes at least two drawers or adequate dresser space. The facility has a sufficient supply of linens to permit weekly changing or more often to always insure clean linens for residents. Equipment and supplies for resident personal hygiene is available and on site. Activity supplies are available for residents. As the facility has an approved fire clearance for hundreds of residents, there is a signal system required and observed by LPA. Refrigerators and freezers are maintained at an appropriate temperature Fahrenheit as per CCL regulations. Food storage and preparation areas, including pantries, cupboards, counters, etc., are clean and appropriate for food preparation. The food service areas are clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. Multiple locked storage areas for central storage of medications were observed by LPA, depending on the area of the facility. Cleaning supplies are kept in areas separate from where food supplies are stored. Walls, ceilings, floors, carpeting, window screens, and areas around the facility are clean, painted and/or in good repair. There are locked storage area(s) for poisons, toxic, cleaning solutions, disinfectants, etc. Fire extinguishers and smoke detectors operate properly. Doors and passageways are unobstructed. There are no pools/bodies of water on the physical plant of the facility as observed by LPA. During the inspection, LPA did not observe any firearms that would require trigger locks, locked and inaccessible, or firing pins removed. At the time of the visit, all common areas/interior rooms of the facility were observed to be appropriately furnished, with all furniture in good condition. There are multiple fireplaces on the premises, which were all covered and inaccessible to residents. The facility contains common areas such as a billiard room, auditorium, and life enrichment center building that includes arts/crafts rooms as well as exercise/gym rooms for residents. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguishers were fully charged and are serviced annually. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity materials in the common areas of the facility in good repair and operating condition. The facility maintained a comfortable temperature in all areas inspected. There is appropriate lighting in all the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all changes in incline are well lit with sturdy hand railings/stair chair accessibility devices. All window screens were in good repair. Continued on 809-C There is a pool area in the facility, which is appropriately fenced and gated with adequate supervision. LPA did not observe any noticeable outdoor hazards. Outdoor activity spaces in the facility are shaded and equipped with furniture for resident use. All outdoor areas with stairways, inclines, ramps, or open porches have accessibility ramps for residents, and are well-lit. The facility has adequate storage of additional supplies/emergency supplies. The designated laundry area in the facility has appropriate storage of cleaning products, which are kept locked and inaccessible to residents. Emergency food and water in storage were observed to be in good condition by the LPA. Cleaning supplies, disinfectants, and other items that could pose a danger are kept in areas inaccessible to residents. Vehicles used to transport residents are in safe operating condition with appropriate insurance information. The facility is comprised of many separate buildings for multiple uses, including a life enrichment building with fitness center and art/craft rooms, pool(s) with jacuzzi(s), resident clinic, mailroom, and specific activity rooms such as pottery and jewelry making. There is a main entrance road into the facility and an administrative entrance area for visitors. The facility has fences surrounding the backyard area of the memory care portion of the facility, with electronic combination delayed egress entrances/exits. The facility has an outdoor patio area for residents outside of the resident restaurant grill. The pool/body of water and jacuzzi comply with all safety instructions per the regulations. Outdoor activity spaces and the dining patio for residents are equipped with furniture for resident use. Electronic devices are in place to monitor exits of the memory care building in the facility, if exiting presents a hazard to any resident. The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms in the facility were sufficiently stocked with soap, paper towels, required postings, and clean trashcans with closed lids. Towels and washcloths are not shared by residents in the facility. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per Title 22 regulations between 105-120 degrees Fahrenheit. There are an adequate number of toilets per residents in the facility. Nightlights are installed as observed by LPA. All toilets and hand washing areas are maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences are available accommodate any physically handicapped residents who need such items. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Each resident bedroom has a bed, nightstands, and lights and nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms can store or has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. Continued on 809-C The resident bedrooms are big enough for all beds, furniture, and any resident assisting device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. The facility has provisioned to each resident of furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. An emergency exiting plan and emergency phone numbers are posted in an appropriate place. A current disaster and mass casualty plan maintained at the facility. The facility’s policies and procedures as it pertains to infection control are adequate. First-aid supplies, which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual, are maintained. Administrator’s records, employees and resident records are maintained at the facility and available for review by the LPA as employees are hired and residents accepted into the facility. The facility complies with CCL standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Admission agreements and needs and services (ANS) plan are maintained for each resident and/or their authorized representative. Resident records are maintained on the facility premises in a secured area. Centrally stored medications are locked in secure locked cabinet(s) inaccessible to residents. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. LPA audited the medications for residents and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility. The facility administrator meets the qualifications as specified in Title 22 regulations. Administrator has a current RCFE administrators’ certificate with an expiration date of 12/03/2025. There are required postings throughout the facility, including emergency exit plans with necessary telephone numbers. Provider Information Notices are available and able to be presented to Staff, residents, visitors, and accessible to LPA upon request during the inspection process. Exit interview conducted by LPA. Copy of this report provided to the facility.