Routine inspection·May 22, 2023

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection. LPA met with Executive Director (ED) Jolie Higgins. During visit, LPA toured the facility with ED to include the entrance, dining room, kitchen, memory care, assisted living, hallways, and office spaces. Facility temperature maintained between 71 - 72 degrees Fahrenheit. Fireplace observed adequately screened at the entrance. Facility's license is posted in the hallway. Posters such as the Ombudsman, if you see something say something, emergency disaster plan, and personal rights poster posted in the hallway. Facility kitchen observed clean and sanitary. Facility has an adequate amount of dishes and silverware. Sinks observed with hygiene products and hand washing signs. Special diet paperwork posted in a visible area. Facility observed with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator maintained at 33 degrees Fahrenheit. LPA observed food items in the refrigerator were not properly covered to include a whole container of lettuce and deli turkey meat. The freezer's temperature states the temperature is maintained at 9 degrees Fahrenheit. ED states they have contacted the contractor for the freezer to adjust the thermometer. Fire extinguisher in the kitchen last serviced on 05/13/2022. The facility is scheduled to service their fire extinguishes on 05/31/2023. LPA entered Compass Rose (memory care) with the ED. LPA inspected room 138 and observed cleaning supplies and laundry detergent accessible to 2 out of 2 residents living inside the apartment. The cleaning supplies and laundry detergent were removed from the apartment. LPA inspected room 126, 129, and 121B; each room contained proper furniture, lighting, and linens. Sharp objects and chemicals observed secured. LPA observed residents attending an activity in the dining room. LPA did not observed a planned activities calendar was posted. The compass rose kitchen refrigerator contained an uncovered pitcher of an unknown liquid substance. ED stated the substance smelled like apple juice and was immediately thrown out. SEE LIC809-C. The compass rose exterior passageways was free and clear of obstruction. LPA inspected the exterior's 2 delayed egress doors with ED. LPA and ED observed 1 out of 2 delayed egress doors did not alarm and unable to open. During visit, the facilities maintenance director fixed the delayed egress door and LPA observed the door alarmed and properly open. LPA entered the compass rose medication room and inspected 3 residents (R1 - R3)'s files to include their physician's report, TB, appraisal needs and services plan, consent to treat, and centrally stored medication records. LPA observed the centrally stored medication records were not being maintained to include incomplete and/or inaccurate items such as start dates, refills, instructions, and prescription numbers. LPA observed at least 4 medications of R3's were not written in the centrally stored medication record. LPA entered the Assisted Living area with the ED. LPA observed an activities calendar posted in the common area. LPA entered rooms 225, 229, 235, 244, and 247. LPA interviewed 5 residents (R4 - R9). LPA entered the AL medication room and reviewed resident R4 - R9's files. R4 - R5 are not on medication management. 2 random residents (R10 - R11) centrally stored medication records were inspected to be maintained. Staff files observed to include training, CPR certification, medical assessments, fingerprint clearance, and employee rights forms. All staff observed are fingerprint cleared and associated to the facility. Emergency fire drill and elopement drills conducted every month with staff on every shift. Facility is equipped with a carbon monoxide and fire extinguishers throughout the facility. Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with the Executive Director (ED), Jolie Higgins and Resident Service Director, Ria Hernandez and a copy of the report and appeal rights was provided.