Routine inspection (multi-day)·November 5, 2024

At approximately 9:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a 1-Year Required Visit and met with Executive Director/Administrator, Juliet McGranahan, and Resident Care Director, Lorena Madrigal Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 75 non-ambulatory residents of which 10 can be bedridden. Facility has an approved hospice waiver for 15 individuals and has approval for a secured perimeter. Upon arrival, LPA was informed that there were 63 Residents in care and 20 staff members on-site. LPA conducted a walk-though of the facility with Resident Care Director. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is comprised of 5 separate houses for residents, 1 office building, and facility kitchen. Each house has 13 resident rooms, 3 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to Residents. LPA observed that 4 of 10 sinks accessible to residents were out of compliance with Title 22 Regulations, measuring at 147.2F, 128.6F, 125.7F, and 138.2F (deficiency cited, LIC809D, regulation 87303(e)(2)). LPA reviewed staff files, resident files and resident medication. During staff file review, LPA observed 6 of 8 staff files had current First Aid and CPR certification (Technical Violation issued, LIC9102, Regulation 87411(c)(1)). LPA also observed that 8 of 8 staff files did not have annual 2024 training conducted as required by Health and Safety Code (deficiency cited, LIC809D, H&S Code 1569.625(b)(2)). During resident file review, LPA observed that 1 of 5 residents did not have an updated Physician's Report (LIC602) as required (technical violation issued, LIC9102, regulation 87705(c)(5)). During medication review, LPA observed that 4 of 10 resident medication was not centrally stored and logged as required (deficiency cited, LIC809D, regulation 87465(h)). Continued on LIC809C Continued from LIC809 Administrator's Certificate for Juliet McGranahan (6071164740) was current with an expiration date of 07/10/2026. LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610E) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Active and Current Administrator Certificate Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 12/06/2024. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director and Resident Care Director. Signature on form confirms receipt of documents.