Routine inspection·February 19, 2025

Licensing Program Analyst (LPAs) Christi Coppo and Ali Deniz arrived unannounced to conduct a required Annual inspection and was greeted by receptionist. Administrator Robert Alvarado arrived later. Facility contact information was reviewed. At approximately 9:45am LPAs toured the building and grounds. LPAs toured main kitchen and found it to be clean and organized. LPAs observed speed rack of sandwiches and salads that were not covered with plastic. LPAs and Director of Food Services (DFS) discussed getting a cover/tarp for the speed rack. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner but many open items not covered with tight fitting lid, such as ice cream and veggie burger patties. LPAs and DFS discussed ensuring all items that are open or pre-made must be wrapped or covered with a lid. LPAs toured emergency food and water supply room, facility has supply within regulation. LPAs measured temperature of water in main kitchen to be 148 degrees F but did not have a caution hot water sign above sink; however, a caution sign was observed on ancillary sink in kitchen. LPAs and DFS discussed putting a caution sign above main sink. LPAs measured temperature of water in kitchen by Activity Director's office to be 109 degrees F, which is within the allowable range of 105 to 120 degrees F Fire extinguishers were last inspected both on 2/12/24 and 4/10/24. Fire extinguishers last inspected 2/12/24 were charged and arrow showing in the green. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired and serviced by a vendor. Director of Maintenance (DOM) explained to LPAs that a vendor came to the facility that DOM thought was the vendor that served the fire panel but DOM was mistaken and company tampered with fire panel box such that it was rendered to not working properly. Vendor that actually does service came on 2/11/25 and the Automatic Sprinkler System failed inspection. Deficiencies found were listed as: riser pressure gauges are over 5 years old and need to be replaced, four Continued on 809C... Continued from 809... in total; the water flow switch for the 1st and 2nd floor sprinklers didn't activate into alarm when tested. A purchase order was placed for the risers and another 5 year inspection will be conducted with a date yet to be determined ( deficiency cited, see 809D ). Facility’s last quarterly disaster drill was conducted 1/29/25. Facility has a backup generator for use during a power outage. LPAs toured Memory Care unit and found the unit to be at a comfortable temperature with residents engaged in activity or watching T.V. LPAs measured temperature of water in Memory Care kitchen to be 110.4 degrees F which is within the allowable range of 105 to 120 degrees F. LPAs observed trash, food scraps and pieces of discarded food items, cup with black substance and white substance, and used paper towels to be discarded and piled up underneath sink ( deficiency cited, see 809D ). LPA observed notable urine smell coming from room next Sauna room in Memory Care ( deficiency cited, see 809D ). At approximately 11:00am LPAs conducted review of 7 staff records. Staff (S1, S2, S3, and S4) did not have the total required hours of training completed ( deficiency cited, see 809D ). Seven staff (S5, S6, S7, S8, S9, S10, and S11) were listed on staff roster but did not have fingerprint clearance ( deficiency cited, see 809D and civil penalty assessed ). LPA, Admin, and Business Operations Manager Danielle Oseguera (BOM) discussed those staff not having fingerprint clearance. BOM concerned as she remembers waiting for the clearance before putting them on the floor; however per Gaurdian S5-S11 do not have any applications and do not have clearance. Additionally two [2] staff listed on staff roster were not associated to the facility. LPA and Admin discussed staff not present on Guardian roster that were listed as current staff on facility roster. Admin advised that for some reason these employees are listed as separated in Guardian but are not actually separated. Admin and BOM showed LPA on Guardian site the separation dates of this staff. Admin agrees to go back in and re-associate each one. At approximately 12:00pm LPAs conducted a review of 7 resident records. All documentation present. Continued on 809C(2)... Continued from 809C... At approximately 3:00pm LPAs and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies At approximately 4:15pm LPA walked facility grounds. No obstructions found. Evacuation chair present in stairwell. Robert Alvarado Administrator Certificate 7017266740 is currently expired. LPA called Administrator Certification Bureau and was told by the representative that the certificate was in renewal status but was subsequently removed from pending status due to not having enough training hours completed and required forms not submitted ( deficiency cited, see 809D ). Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with BOM and a copy of this report was given . ***Due to computer problems citations and civil penalties not printing. LPA obtained signatures for 809 and 809C pages and will return at a later date to complete issuing of citations and civil penalties as part of annual inspection.***