Routine inspection·May 13, 2024

Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual inspection of facility and met with Ami Kumar, Licensee and Janine Sorenson, Administrator. Facility has 6 residents in care, 2 receiving hospice care and 5 residents with dementia diagnosis. At approximately 11:10 AM LPA & Administrator toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All residents have call buttons and motion sensors which sound in kitchen area. All notices that are required to be posted have been posted and are in a highly visible area. Facility has an approved dementia plan of operation. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in locked laundry room, hallway closet and under locked kitchen sink. Water temperature measured between 127.2 degrees F to 128.8 degrees F falling out of regulation between 105 and 120 degrees F in 5 out of 5 faucets accessible to residents in care. Licensee turned water heater down at time of visit. (see LIC809-D) There was an ample supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. Fire extinguisher inspected was last charged on 12/28/2023. Smoke detectors and carbon monoxide detectors were tested and found to be in working order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in med room off of kitchen which also contains a small refrigerator with lock for medication. Facility to ensure that approved Admissions Agreements are always posted and/or accessible to public view in the facility as per Title 22 Regulations # 87507 (e)(2) Admissions Agreement “The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement , modifications and attachments, or notice of their availability from the facility.” Continue on LIC809-C At approximately 12:30 PM, LPA reviewed 5 of 5 resident records and found 5 of 5 residents have current physician’s reports and updated care plans. 5 of 5 resident records contained current and signed admission agreements and physician’s orders on file. Hospice care plans are up to date and current. At approximately 1:50 PM, LPA review 5 of 5 staff records. 5 of 5 records contain documentation of completed training records as required. Evidence of current first aid and CPR training were observed. Staff S1 records did not contain current TB (see LIC809-D). The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 5/13/2024 at 2:30 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. At approximately 12:30 PM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts quarterly disaster drills with the last disaster drill conducted on 4/15/2024. Janine Sorrenson Administrator Certificate #6039492740, expired 5/4/2024 and provided LPA confirmation of pending certificate. LPA reviewed Licensing Information System (LIS) with Licensee who stated that is corrected and updated at this time; no need to change any of the information. Appeal Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided. LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 6/5/2024: LIC 308 Designation of Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (if changed) LIC 9020 Register of Facility /Resident’s Control of Property – Lease or Deed Copy of Administrator’s Certificate Proof of Liability Insurance