Routine inspection (multi-day)·November 15, 2024

At approximately 9:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Kelly Yee, Administrator. Facility is a Continuing Care Retirement Community (CCRC) with a combined total of 69 residents currently residing in the assisted living and memory care units. The community is approved for a total capacity of 743 residents, of which 223 residents may be non-ambulatory. The community has a Hospice waiver for 6 residents, and there is an approved delayed egress system in place in the memory care unit. At approximately 10:10 AM, LPA initiated a tour of the community's Quail Creek and Willow Creek Assisted Living Facilities and the Deer Creek Memory Care Facility and observed the following: The Quail Creek facility is a three story building and the Willow Creek and Deer Creek facilities are both one story. Each building was a comfortable temperature, and passageways were free from obstructions. LPA observed the required evacuation chairs in stairwells. Water temperature in 4 of 16 residents' bathrooms measured outside the allowable range of 105 to 120 degrees F per Title 22 regulations, (see LIC809D). LPA observed a supply of hygiene, paper, and incontinent care products available for residents. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets and storage rooms containing cleaning supplies and other items that could pose a risk were locked. Community has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Food was covered, labeled, and stored in accordance with regulation. LPA advised the head chef in both the Quail Creek and Willow Creek kitchens to ensure that all expired food is consumed or disposed of by the expiry date. Medications were centrally stored and locked. The community has a fitness center with a class schedule posted with multiple classes per day offered to residents, an indoor pool, tennis courts, a massage room, a beauty salon, daily activities, crafts, puzzles, music, movies, reading areas, and more for residents in care. Continued on LIC809-C... Continued from LIC809... There are covered patios and seating areas throughout the community with outdoor space for activities. The community has internet service available to residents in care. The community's fire extinguishers were observed charged and were last serviced 11/2023. Smoke and Carbon Monoxide detectors were last inspected 6/2024 and are inspected semi-annually. The automatic sprinkler system is inspected semi-annually and was last inspected 8/2024. The community conducts regular monthly disaster drills, and the most recent drill was conducted 10/2024. LPA observed the community's infection control plan and the emergency disaster plan which was last updated 12/2023. LPA observed a supply of PPE, emergency supplies, and flashlights, as well as a first aid bag in each building. Administrator states the community has several back up generators. At approximately 12:30 PM, LPA began file review of 10 staff files and 10 resident files. 7 out of 10 resident files reviewed did not have the Needs and Services Plan signed and dated by the resident and/or their responsible party, (see LIC809D). Administrator advised to ensure all forms are signed and dated, including consent for emergency medical treatment and personal rights. 10 out 10 resident files reviewed had all the remaining required documentation. 7 out of 10 staff files reviewed were missing the required first aid training, (See LIC809D). 4 of 10 staff files reviewed were short of the some of the specific annual training hours required, (see LIC809D). LPA advised Administrator to ensure that the required initial training hours are documented in accordance with regulation. 10 out 10 staff files reviewed had all the remaining required documentation. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit : LIC500- Personnel Report LIC610- Emergency Disaster Plan A copy of community Liability Insurance The following deficiencies were observed and cited (see LIC 809-Ds) from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Administrator whose signature on form confirms receipt.