Routine inspection·August 28, 2025

On 08/28/2025, Regional Manager (RM), Stephenie Doub and Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. RM Doub and LPA Pascua were greeted by Facility Designated Administrator (FDA), Ravjir Sandhu and explained the purpose of the visit. The purpose of the visit was to conduct an annual visit. Current census was 41. A brief interview with FDA Sandhu was conducted. This facility is licensed to served residents who are 60 and over with a capacity of 73. 73 of 73 residents may be deemed non-ambulatory. 10 of 73 may be bedridden. This facility also has a hospice waiver for 16 residents. It was learned that there were a total of 11 residents on hospice. LPA reviewed 5 resident files and 5 staff files. It was observed that 5 out 5 resident files did not have an updated Needs and Services Plan. It was observed that 1 out 5 staff did not have an First Aid/CPR on file. 1 out of 5 staff did have First Aid however CPR was not on file. 1 out 5 staff files did not have the mandated reporter statement signed and 1 out 5 staff files did not have their application on file. The Facility Designated Administrator has an active certificate #6069560740 and expires on 11/20/2026. LPA reviewed that fire drill log and is in compliance at this time. A tour of the facility was conducted with FDA Sandhu. This facility has a main building in which has 4 separate wings, Napa, Central Valley, Yosemite and Carmel. Currently, there are no residents residing in Carmel. A separate building, Monterey was also observed and toured. LPA observed a small kitchenette that is equipped with microwave and an addition refrigerator present to cool, heat, and warm up food of the residents if necessary. It was learned that resident bedrooms have been equipped with pull cords were observed. A review of the resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. It was learned that this facility has a signal system in resident bathrooms. LPA Pascua observed a fire extinguisher in Monterey and all wings that were services by Fire Master on 08/06/2025 and is in compliance at this time. Kitchen area was toured. Facility freezer and refrigerator units were toured. LPA reviewed the food storage supply to make sure that there was always a 2-day perishable and 7-day nonperishable food quantities on site at all times. Storage area for chemicals and cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Additional incontinent supplies were also identified. A medication room was identified and tour. Medication carts for all four wings was reviewed and the policies for dispensing, storing, and documentation was discussed with facility staff responsible for the medication management at this time. It was observed while comparing Electronic Medication Administration Record that the facility did not have an order for R1's medication on file. Further review shows that the facility did not have this medication on the EMAR since 01/15/2025. In addition, it was observed that the facility had medication poured into plastic containers for noon medication pass. First aid kit was observed to be present and contained all of the required components at this time. Perimeter fence and gates were observed. It was observed that the black gates next to the exit gate had a padlock attached which prohibited access to the back gate. The following forms and documents were requested to be updated and submitted into CCL for review by this LPA: LIC 308 LIC 400 LIC 500 LIC 610 Licensees were offered and agreed to an opportunity to participate in Department's Technical support Program. The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.