Routine inspection·July 25, 2024

Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct an Annual Required - 1 Year inspection, at approximately 11:25am on 7/25/24, and met with Administrator Megan Leone. Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has an approved dementia plan. The facility has a hospice waiver approval for ten (10) residents. Fire clearance is approved for one hundred and seventy-three non-ambulatory, of which 16 may be bedridden; Capacity breakdown as follows: main building, and the five (5) bungalows are cleared for one hundred and forty (140) non-ambulatory, of which six (6) may be bedridden, the memory care building is cleared for thirty-three (33) non-ambulatory, of which ten (10) may be bedridden, total license capacity is one hundred and seventy-three (173) . The delayed egress is approved, per fire clearance. LPA reviewed nine (9) resident files. LPA reviewed nine (9) staff files. All staff had required criminal record clearance. All staff had required first aid certification, and cpr certification. All staff have required training. Medications and medication records were reviewed. Per review of the emergency disaster drills binder, the facility is completing quarterly drills as required; Fire drills held on 6/6/24, 6/11/24, and an evacuation drill held on 4/30/24. The LPA toured the facility, main building and memory care building, with Administrator Megan and Joel Gonzalez, Business Office Director. Hot water was checked at 119.3 degrees Fahrenheit in the main building and 111. degrees Fahrenheit, which are both within regulation compliance. All exits were clear and unobstructed. Facility fire extinguishers were serviced and tagged as required. All stairwells had evacuation chairs and posted instructions for staff if needed in an emergency. Continued on LIC809C... Emergency disaster plan binder is kept at the concierge desk, and all staff have access as needed in case of an emergency. The plan and identified staff for emergency response was posted up in the copy/mail room, which is the room behind the concierge area. All keys to units and vehicles are in lock boxes accessible by staff on every shift. Food supply was sufficient. Facility had a sufficient supply of emergency food, water, miscellaneous supplies to meet the required 72 hour in place requirement. Facility had a sufficient supply of disinfectants/cleaners, paper products, hygiene products, and personal protective equipment (PPE). The facility had sufficient lighting in all common areas, bathrooms, and hallways. Bathrooms observed by the LPA had grab bars and non-slip flooring/mats as required. LPA is requesting the following documents be updated and submitted by 8/25/2024: LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required-if no changes, submit the last page with date/signature reviewed) Infection Control Plan (ensure to review and update as needed/required-if no changes, submit the last page with date/signature reviewed) 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 There are no deficiencies cited during today's visit. Exit interview conducted with Administrator Megan Leone.