Routine inspection·April 26, 2024

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility annual required 1 - year inspection. LPA met with Executive Director (ED) Lola Bullock. LPA toured the facility inside and outside with ED to include the independent living, assisted living, and memory care unit. All fire exit routes were free and clear of obstruction. Stairwell observed to include an evacuation chair. Elevator in working condition. Activities calendar posted throughout the facility in the independent / assisted living unit and memory care unit. LPA observed residents participating in various activities throughout the day. Facility temperature maintained between 71 - 72 degrees Fahrenheit. Fire extinguisher was last services in July 2023. Facility has a carbon monoxide detector present. With the assistance of the ED, LPA entered into rooms #426, #402, #309, #326, #238, #243, #220, #206, #102, and #105. 10 out of 10 apartments observed with a bed, clean linens, adequate lighting, night-stand, chair, and dresser. Bathrooms observed with grab bars and non-slip mats. Hot water temperature in RM #426, #309, #243, and #102 maintained between 106 - 120 degrees Fahrenheit. Medication carts observed locked. LPA observed chemicals, disinfectants, sharp objects, and medications observed locked in memory care. Facility kitchen observed clean and well maintained. Refrigerator temperature maintained at 38 degrees Fahrenheit and freezer temperature maintained at 0 degrees Fahrenheit. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Food items in the refrigerator observed covered. Dining room equipped with utensils, plates, cups, and napkins. SEE LIC809-C. LPA reviewed 11 resident files. 11 out of 11 resident files observed maintained to include an updated medical assessment, TB result, updated needs and services plan, identification emergency information, admission agreement, consent forms, and personal rights. 3 out of 4 resident files contained a physician's order for a postural support. ED was advised regarding 1 out of 4 residents. 11 residents centrally stored medications and centrally stored medication records were reviewed. LPA observed multiple PRN medications for 5 out of 11 residents were not recorded in the centrally stored medication record binder. The medications that were not part of the centrally stored medication record binders were filled in 2023. Staff stated the CSMR is now archived in the facility's attic, however, the medication is documented in their Electronic - Medication Administration Record. ED was advised. LPA reviewed 6 staff files to include a 1st aid certification, health screening, TB result, personnel record, fingerprint clearance, and training records. LPA was unable to review 1 out of 6 staff health screening and TB result. 2 out of 6 staff files observed contained a 1st aid certification. 6 out of 6 staff are fingerprint cleared. LPA did not observed 2 out of 6 staff members received at least 20 hours of annual training to include topics to include but not limited to dementia, postural supports, restricted health conditions, and hospice care. Facility has an emergency disaster plan. Emergency drills are being conducted quarterly. LPA reviewed the infection control plan and infection control training. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Advisory notes provided. This report was reviewed with Executive Director, Lola Bullock and a copy of the report and appeal rights were provided.