Routine inspection·April 2, 2025

Licensing Program Analysts (LPAs) Alviso and Contreras conducted a Required - 1 Year visit, on 4/2/25 at approximately 9:00am, and met with Gao Yang-Journey Director. Facility has a required infection control plan, and a required emergency disaster plan. Hospice care waiver approved for thirteen(13) residents. Facility has an approved dementia plan of operation. Fire clearance is approved for 80 non-ambulatory residents, which includes 4 bedridden. Per LPAs file reviews, the facility is conducting required emergency disaster drills; On 3/17/25 fire drill, 2/13/25 fire drill, and 12/9/24 fire drill/evacuation training. On 3/27/25 the staff had an elopement drill. Training drills are done to cover staff on all shifts. LPAs reviewed ten (10) resident records. All records were complete. LPA reviewed resident (R11) medication records; LPA was provided copies of requested records. LPA obtained additional information regarding current medication orders and how medications are being provided. The LPAs reviewed ten (10) 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. LPAs toured the facility with the Gao Yang-Journey Director, and Jose Moreno-Maintenance Director. Facility was observed to be clean, orderly, and at a comfortable temperature. LPA observed all exits free and clear from obstruction. LPA observed random fire extinguishers which were serviced and tagged as required. Common areas, hallways, and bathrooms observed by the LPA had sufficient lighting available to residents in care. Continued on LIC809C... The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility had a sufficient supply of food, water, and other emergency supplies to meet the seventy-two (72) hour shelter in place requirements. 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 instructions posted up. The facility has three generators, and emergency disaster supplies stored in case of an emergency. Hot water was measured at 119.8 degrees Fahrenheit in memory care on the 1st floor, and 114.4 degrees Fahrenheit on facility's 2nd floor; Both hot water measurements were within regulation. Facility had a sufficient supply of cleaners/disinfectants, paper products, hygiene products, and personal protective equipment (PPE). Cleaners/disinfectants were locked up and inaccessible to residents in care. Medication rooms, in assisted living and in memory care were locked and inaccessible to residents in care. There are small refrigerators in the medication rooms which are used for any medications needing to be stored and refrigerated. Medications were stored in compliance with State and Federal requirements. LPAs observed the beauty salon to be in operation during the inspection; The salon's door has a lock to secure the beauty salon as needed/required when not staffed. All outside courtyards were clean, pathways were clear of obstructions, and had outside furnishings and shaded areas for resident use. LPA is requesting the following documents be updated and submitted by 5/2/25. 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 by all facilities Copy of Current Liability Insurance Copy of current Administrator Certificate No deficiencies cited during today's inspection. Exit interview conducted with Journey Director Gao Yang.