Routine inspection·August 16, 2024

Licensing Program Analysts (LPAs), Alviso and Loera, arrived unannounced to conduct a Required-1 Year Inspection. Stationed at the front entrance of the facility there is a security guard who screens visitors upon entry; LPAs were provided a parking pass and allowed entry onto the grounds. LPAs met with Administrator Bill Keck, Skilled Nursing Administrator Dan Skillman (back-up RCFE Administrator), and Director of Resident Health Services (RHS), Sharon Shnell-Hobbs. Fire clearance is approved for six hundred and seventy-nine (679) may be non-ambulatory, of which two (2) may be bedridden. Hospice waiver approved for forty (40) residents. Approved delayed egress in memory care unit. Facility has a required emergency disaster plan. Facility has a required infection control plan. Last evacuation drill was held on 6/7/24, and last fire drill was 6/7/24, per review of records. LPA discussed the emergency plan regarding emergency drills, these are to be conducted quarterly per H&S Code. LPAs reviewed five (5) resident files. All were complete. LPAs reviewed five (5) staff files. Staff had criminal record clearance as required. Staff had first aid and CPR certification as required. Staff had required training. LPAs toured the facility grounds with RHS Sharon, memory care unit, and assisted living units.pendent units. Hot water was checked at 119.1 degrees Fahrenheit. All exits were observed to be clear of obstruction. Fire extinguishers were tagged and serviced- dated 1/9/2024. LPAs observed a sufficient supply of food. Medications were centrally stored as required, including refrigerated medications. Medications are kept in medication carts, including double locked narcotic medications. All exits doors, walkways, and breezeways had sufficient room for residents to ambulate and were found to be clear. LPA is requesting the following documents be updated and submitted by 9/16/24. LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report -ensure all staff are listed/titles/days & hours working LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required) Continued on LIC809C.. Infection Control Plan (ensure to review and update as needed/required) Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed by all licensees. Copy of current Administrator Certificate Deficiencies observed during the inspection. LPAs observed that two (2) stairwells out of four (4) lacked the required evacuation chair; This was the building that consists of assisted living units, and a memory care unit. LPAs observed in the additional 14 buildings, having a total of 28 stairwells; 12 of these stairwells lacked the required evacuation chair, per H&S Code. This deficiency will b cited, HSC 1569.695(f)(1) Emergency Plans - An evacuation chair at each stairwell, on or before July 1, 2019, see LIC809D. LPAs obtained photos. LPAs observed two (2) housekeeping/cleaning carts that had numerous cleaners/disinfectants stored in them and unlocked, making them accessible to residents in care, one unsupervised cart was outside in the walkway of assisted living units, the other unsupervised cart was in an assisted living building, turned around and facing a wall. This deficiency will be cited, 87309(a) Storage Space- Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients, see LIC809D. LPAs obtained photos. Deficiencies cited 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. Appeal rights provided to the Administrator. Exit interview conducted with Administrator Bill Keck.