Routine inspection·February 27, 2024

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection to the above-named facility. The facility is licensed as a Residential Care Facility for the Elderly (RCFE). Upon arrival, LPA met with Executive Director Robert Glock and announced the purpose of the visit. Administrator Karolyn Sorenson was not available at the time of the visit. The facility is licensed for 126 non-ambulatory residents and a hospice waiver for 10 residents. Currently, there are 88 residents residing in the facility.There is one resident currently on hospice. Entrance Interview Conducted: The facility is four stories with no bodies of water. Entrance into the facility is the Ground floor which leads into a large common area, reception area, administrative offices, and a large dining area. There is an outdoor patio off the dining area conducive for social distancing. Also on the ground floor are an activity room, activity offices, hair salon, laundry rooms, a library, and the kitchen. The kitchen is a large industrial size kitchen consisting of grills, ovens, heating lamps, fryers, industrial size refrigerators and freezers, large pantries for food storage, and a dishwashing station. Floor #1 consists of Nurses’ station, Nurse’s office, testing room, approximately 74 residents’ rooms, Physical Therapy/Gym room, an outdoor patio, and a staff break room. Residents’ records are kept in the Nurses’ station on Floor #1. Floor #2 is residents’ rooms only. Floor #3 consists of a rooftop deck with open-air outdoor seating and covered outdoor seating, potted plants, and panoramic views. Residents may participate at will in various activities based on their individual interests and preferences. Activities include mental wellness sessions, historical biographical mapping, book club, garden club, residents' social gatherings, religious study groups, singing groups, chair yoga, eye-hand coordination activity, Bingo, aroma therapy, celebrations of special events and holidays, scenic excursions to local interest sites and excursions to local retail businesses and eateries. Please continue to 809-C, Pg 2. During today’s visit, the medication inventory and Medication Administration Record (MAR) for Resident 1 (R1) revealed an overcount of Aspirin Low Dosage 81mg began on 2/16/2024 with a bottle count of 30. R1’s prescribed medication is 1x per day in the AM administered on 2/16/2024 through 2/27/2024. At approximately 1:52 pm, Staff 1 (S1) counted an overcount of 21 tablets in the bottle. R1’s prescribed medication of Levothyroxine 75 mcg with a bottle count of 30 started on 12/30/2023 MAR revealed R1 did not take one dose on 1/21/2024. At approximately 2:00 pm, S1 counted an overcount of 34 tablets in the bottle. At approximately 2:05 pm, S1 and Executive Director Glock re-counted the Levothyroxine medication and determined there was an overcount of 34 tablets in the bottle. R1 has a Doctor’s order for Memantine 10mg, (60 count) 1 tablet twice per day in the AM and Bedtime. The medication was started on 12/30/2023. At approximately 2:24 pm, S1 counted 46 tablets remaining in the bottle. R1's MAR revealed the medication was administered to R1 from 12/30/2023 through 2/27/2024. During today’s visit, the medication inventory for R1 revealed approximately eight (8) expired medications. At approximately 3:30 pm, Staff 2 (S2) completed LIC622 Centrally Stored Medication and Destruction Record. Executive Director Glock stated the expired medications will be properly destroyed by 2/29/2024. Due to time restraints, LPA will return at a later date to continue the annual inspection. The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.