Post-licensing visit·August 22, 2023

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Post-Licensing Inspection and was welcomed by Business Office Mgr. Elizabeth Alfaro, and met with Administrator Deborah Savoie, who arrived later to facility. Facility is 2 stories and contains both assisted living and memory care with a total of 35 Assisted Living and 39 dementia residents in 2 memory care units. There are 9 residents currently on Hospice. Facility tour/inspection began at 8:35 AM: LPA toured the facility on 8/22/2023 at approximately 8:35 AM with Business Office Manager (BOM) Lizabeth Alfaro; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 10/10/2022. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected annually, and inspection records are current with the last inspection being conducted on 7/15/2023. Every resident apartment has an individual smoke detector in addition to hard wired. LPA observed 3 out of 3 Carbon monoxide detectors that were found to be operational. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 113 degrees F and 121.8 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 6 of 10 resident’s bathroom faucets, all 6 in memory care (see LIC809-D). The facility as special care plan of operation and programming for residents with dementia. Facility serves residents without dementia as well. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Menus are available and provided during meals. Continue LIC 809-C LPA observed that provisions are made for individuals with special dietary needs; facility keeps a variety of items on the menu, and facility has a board in the kitchen with a picture of the resident & a list of dietary needs. Food is available for residents any time of the day. There is a daily activity schedule for residents posted on the wall. Toxins are stored in a locked housekeeping room; although while touring facility at 9:24am LPA & BOM observed unattended unlocked Insulin cart with medication accessible to residents (see LIC809-D). There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with towels and hand soap dispensers when a private room; although at 8:40am LPA & BOM observed in a memory care bathroom an unlocked cabinet with wound cleaner, see pic (see LIC809-D). Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. While touring facility LPA observed Garden Neighborhood dining area blocked off and was informed by Building Services Director Russell Echevira, a leak under the dishwasher has been causing water damage for some time and the floors and a wall in the room have been removed for sterilization. The incident had not been reported as required to the department (see LIC 809-D). File Review began at 11:30 AM: A sample review of five residents & five staff records as well as four resident’s medications was conducted. LPA learned that 5 out of 5 residents have an updated reappraisal/needs & care plan as well as medical assessments. As per sample review of staff records, staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements; although records revealed only 3 of the 5 staff (S1, S2, S3) reviewed had required proof of CPR & 1 st Aid certification (see LIC 809-D). In addition, Deborah Savoie, Administrator Certificate # 6007136740 recertification is pending. Continue LIC 809-C Medication Audit began at 1:20 PM: Medications were centrally stored in locked medication carts and in the facility medication room at the facility. LPA observed medications of 4 out of 4 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 4 out of 4 residents were found to have all medications entered for residents. Facility uses bubble pack and pharmacy CSMR for all residents at the facility. LPA reviewed Licensing Information System (LIS) with Executive Director who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills have been conducted monthly and in different shifts with the last one being conducted on 7/13/2023. At today’s visit LPA is also citing facility for not following reporting requirements. The department received an incident report from facility on 8/16/2023 regarding resident (R1) who on 8/6/2023 was taken to the hospital for fracture of ribs (see LIC 809-D). Civil Penalties are being assessed in the amount of $250.00 for a repeat violation within the last 12 months. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and 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. Exit interview conducted and appeal of rights provided. LPA Hansen is requesting Administrator to update the following documents and to submit to CCL by 9/8/2023: LIC 308 Designated LIC 500 Personnel Summary (already received) LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s(already received) Copy of Administrator Certificate Copy of Certificate of Liability Insurance