Routine inspection·May 21, 2024

Licensing Program Analyst (LPA) Alviso conducted a Required - 1 Year visit, on 5/21/24 at approximately 12:35pm, and met with Administrator Maria Cortes. Hospice care waiver approved for thirteen(13) residents. Facility has an approved dementia plan of operation. Facility has a required infection control plan, and a required emergency disaster plan. Fire clearance approval is for 80 non-ambulatory residents, which includes 4 bedridden. The facility is holding monthly emergency drills, including an evacuation drill; On 3/13/24 an evacuation drill was completed on each shift; Facility understands quarterly drills are to be held, one an evacuation drill, and all drills held on each shift. LPA reviewed eight (8) resident records. All records were complete. The LPA reviewed seven (7) staff records. All staff have criminal record clearance as required by regulation. LPA reviewed staff training records. All staff had required training. Staff have First Aid and CPR certification as required. In review of staff records, LPA observed that the facility hired a staff person that has a class B driver's license, and they can legally drive the facility's vehicle/bus to use for resident activities and/or scheduled transportation, per facility's plan of operation. LPA toured the facility with the Administrator Maria Cortes, and Maintenance Director Jose Moreno. Facility was observed to be clean, orderly, and at a comfortable temperature. LPA observed exits free from obstruction. LPA observed random fire extinguishers which were serviced and tagged. Common areas, hallways, and bathrooms observed by the LPA had sufficient lighting available to residents in care. The LPA observed some residents having their lunchtime meal in the dining room. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility had sufficient supply of food, water, and other emergency supplies to meet the seventy-two (72) hour shelter in place requirements. The facility has three generators, and emergency disaster supplies stored in case of an emergency. Continued on LIC809C... The storage lock box with master keys to rooms and facility vehicles to be used in facility emergencies is in the mail/fax room on the first floor. LPA observed that each stairwell, two (2) had required evacuation chairs, with instruction posted up. Facility had a sufficient supply of cleaners/disinfectants, paper products, hygiene products, and personal protective equipment (PPE). Hot water was checked at 119. degrees Fahrenheit which is within regulation. Laundry rooms had no cleaners/toxins accessible to residents in care, and the rooms were clean and orderly. Medication rooms, in assisted living and in memory care were locked and inaccessible to residents in care. All medications were stored in compliance with State and Federal requirements. There are refrigerators in medication rooms, for any medications needing to be stored refrigerated. LPA observed the beauty salon to be locked, ensuring toxins are not accessible to residents in care. Cleaners/toxins were locked up and inaccessible to residents in care. All outside courtyards were clean, orderly, and had lots of outside furnishings, and shaded areas for resident use. LPA is requesting the following documents be updated and submitted by 6/21/24. 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) 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 Copy of Current Liability Insurance Copy of current Administrator Certificate There are no deficiencies cited during today's visit. Exit interview conducted with Administrator Maria Cortes.