Routine inspection·January 31, 2024

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Administrator, Hiro Kitamura. During visit, LPA toured the facility to include the hallways, resident bedrooms, bathrooms, activity room, dining room, kitchen, and exterior. All staff present are fingerprint cleared and associated to the facility. LPA observed some exit routes were obstructed with a dresser, table with wheels, and a walker. Staff immediately moved the items to ensure the exit routes are free and clear of obstruction. Administrator was advised. Posters observed to include the complaint poster, ombudsman, and rights of resident council. Facility temperature maintained at 72 degrees Fahrenheit. The facility's fire extinguisher last serviced on 09/05/2023. Facility has smoke alarms and carbon monoxide detectors present throughout the hallways. The facility's hallways are lit up by natural light from the outside. Due to the overcast today, LPA observed the facility hallways where resident bedrooms are located were slightly dark. LPA obtained a photograph. Administrator states, during the night the hallways are lit up by 1 light at the end of each hall. LPA advised to install additional lighting in the hallways to ensure the residents safety and comfort during the night. Administrator stated understanding. Administrator also states during the night, they do not have any residents who wander and the residents are assisted with toileting. LPA observed the activity room, dining room, bathrooms, and resident bedrooms contained adequate lighting. Kitchen supplied with cups, plates, bowls, and utensils. The refrigerator temperatures maintained between 28 - 35 degrees Fahrenheit. The freezer temperatures maintained below 0 degrees Fahrenheit. Food items were observed covered and labeled. Facility has at least 2 days worth of perishables and 7 days with of non-perishable foods. SEE LIC809-C. Resident bedrooms were well maintained and free of clutter and odor. The bedrooms contained adequate lighting, bed, linens, chair, and dresser. LPA observed 2 resident beds contained half rails. LPA observed 2 out of 2 residents files contained an order for half rails. Bathrooms supplied with hygiene products, paper supplies, and non-slid mats in the shower. The bathroom next to room #8 hot water temperature maintained at 108 degreed Fahrenheit. The bathroom next to room #3 hot water temperature maintained at 138 degrees Fahrenheit. Administrator was advised. Facility has emergency back-up lighting throughout the hallways. Facility's emergency disaster plan was last updated in 2019. Administrator was advised to update their emergency disaster plan. LPA observed the facility conducts their emergency drills quarterly. The last drill was completed on December 2023. Facility has an infection control plan and sufficient amount of PPE supplies. LPA reviewed 5 resident files. The resident files were observed complete, however, did not contain an appraisal/needs and services plan. Administrator states to be in the process of updating each resident's appraisal/needs and services plan and brought the records to another location. Administrator was advised to ensure the original copies are always in the facility during normal business hours. Administrator stated understanding. 5 out of 5 residents centrally stored medications and records observed maintained. LPA reviewed 4 staff files. Staff files were completed to include an updated 1st aid certification, fingerprint clearance, health screening, and TB result. Staff are provided at least 20 hours of annual training to include but not limited to dementia, postural supports, medications, restricted health conditions, and hospice. 5 residents and 3 staff were interviewed. A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. Advisory notes provided. This report was reviewed with Administrator, Hiro Kitamura and a copy of the report and appeal rights was provided.