Routine inspection·January 14, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Morgan Holien Administrator Certificate 6064643740 expires 3/25/26. At approximately 9:30am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA 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 with open items covered. In addition to open items being covered, LPA discussed with Admin that all opened items should also be labeled with date of opening. LPA and Admin observed disinfectants and cleaning solutions in unlocked cabinet in ancillary Assisted Living Dining room ( deficiency cited, see 809D ). Hot water temperature was within regulation at 123.6 degrees F; however, LPA, chef, and Admin discussed putting up warning signs of water temperature over 125 degrees F as a precaution. Facility has Independent Living (IL) and Assisted Living (AL) residents. Facility does not offer Memory Care. LPA toured selected AL resident rooms: #149, #151, and #161. All bedroom bathrooms were equipped with an emergency pull cord and grab bars. Water temperature in sink accessible to residents in care measured at 116.2 degrees F in room #149, 113.8 degrees F in room #151, and 117.1 degrees F in room #161, which are within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 12/7/24. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired, last serviced by vendor on 10/29/24. Facility’s last quarterly disaster drill was conducted 11/26/24. Facility equipped with elevators, last service date 5/2/24. Continued on 809C... Continued from 809... At approximately 11:00am LPA conducted a review of 6 resident records. No deficiencies. At approximately 12:00pm LPA conducted review of 5 staff records. Five [5] out of five [5] staff (S3, S4, S5, S6, and S7) did not have the required hours of training completed ( deficiency cited, see 809D ). Three [3] out of five [5] of the reviewed staff files were the files of employees assisting residents with self-administration of medication. LPA and Admin discussed Health and Safety Code (HSC) 1569.69 which covers employees assisting residents with self-administration of medication training requirements. LPA and Admin discussed the medication test referenced in the HSC that is required for all those employees assisting residents with self-administration of medication. Four [4] out of five [5] staff (S3, S4, S5, and S6) did not have 1st Aid/CPR on file ( deficiency cited, see 809D ) LPA and Admin reviewed Guardian roster in comparison to current staff roster. Two [2] staff members (S1 and S2) were found to not have fingerprint clearance ( deficiency cited, see 809D ). At approximately 3:00pm LPA and Health and Wellness Director (HWD) conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. No deficiencies. LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates. 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 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 Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties . Exit interview conducted with Administrator and a copy of this report was given .