Routine inspection (multi-day)·February 13, 2024

Licensing Program Analyst(LPA) Alviso conducted a continued annual inspection, on 2/13/24 at approximately 1:30pm, and met with Tamra Richmond-Business Office Manager. Administrator was not available to meet with the LPA. The annual visit was started on 1/24/24, see LIC809 of that date. The facility has a required infection control plan . Hospice waiver is approved for ten (10) residents only. The facility has a required emergency and disaster plan. Facility is fire cleared for seventy-five (75) non-ambulatory residents- effective 1/19/24; Fire cleared resident rooms/units are 157-187 on the first floor, and 257-287 on the second floor. Last fire drills were held on 1/31/24 and 1/17/24, per review of the facility's emergency drills binder. An elopement drill was held on 1/24/24, per review of the facility's elopement drills binder. LPA observed that all stairwells of the facility had evacuation chairs, to be used as needed for residents in an emergency. There was a sufficient supply of food, perishable and non-perishable. All resident bathrooms have grab bars, and non-slip flooring and/or mats for use as needed. The medications were locked up and stored appropriately as required. There was a sufficient supply of personal protective equipment (PPE) to use as needed. LPA reviewed resident files. All files were complete. LPA reviewed staff files. All staff have required criminal record clearance. Six (6) out of eight (8) direct care staff didn't have first aid, per file reviews. This deficiency will be cited, Personnel Requirements - General Section 87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross, see LIC809D. Deficiencies will be 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 . Exit interview conducted with the Administrator.