Routine inspection (multi-day)·November 30, 2023

On 11/30/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a required 1 year annual inspection. LPA Jensen met with Health and Wellness Director Teri Ford and explained the purpose of today's visit. Grounds The grounds were observed to be maintained and all paths were free of obstruction. The facility maintains adequate outdoor furniture. There are shaded areas for the clients to enjoy outdoor activities. The facility maintains outdoor water fountains that have determined to be in compliance. Physical Plant The physical plant was observed to be sanitary and free of odor. The facility temperature was 77 degrees for the comfort of the residents which falls between the required regulatory range of 68-85 degrees Fahrenheit. The fire extinguisher was last serviced in August of 2023 and is in compliance. The smoke detectors and carbon monoxide detectors were observed to be in good working order. The disaster plan was reviewed and is in compliance. The facility furniture and equipment were determined to be in good repair. The common area bathrooms were observed to have open top waste disposal cans. Technical assistance was provided. LPA Jensen toured 6 resident rooms. LPA Jensen observed numerous of bottles of prescription medications, PRN medications and cleaning chemicals such as bleach stored with food throughout the living area for resident 2 (R2). LPA Jensen reviewed the physician's report for R2 and confirmed that R2 is responsible for their own medication administration however the facility is taking no precautions in order to secure the medications and toxins from other residents with restrictions that can freely enter the room. Technical assistance was provided. LPA Jensen tested the water temperature in resident rooms and observed the temperature to range between 106 and 108 degrees Fahrenheit which falls within the required regulatory range of 105-120 degrees Fahrenheit. The facility maintains an adequate supply of linens. The resident units are adequately furnished with beds, night stands, dresser and lamps. Physical Plant LPA Jensen observed the elevators to be in good working order. The facility maintains an evacuation chair at the stair well. All required postings were observed in the correct format and size. LPA Jensen observed a variety of activities available for client engagement including but not limited a full exercise gym, poker tables, shuffle board tables. LPA Jensen toured the kitchen and the dining area. LPA Jensen observed the refrigerator and freezer temperatures to be in compliance. The Ansul system was last served in August of 2023 and is in compliance. There was a 7 day supply of non-perishable food and 2 day supply of perishable food available. LPA Jensen observed lunch service. The facility menu stated that lunch service would consist of a choice between white wine and mushroom chicken or hamburger steak and onions, salad, cheesy mashed potatoes, baked roll, green beans and blonde brownies with nuts. The facility did not have potatoes on hand and made an impromptu substitution with mashed sweet potatoes. Technical assistance was provided. Medication LPA Jensen inspected the medication room in the memory care unit and interviewed a medication technician, staff 1 (S1) and the Resident Care Director, staff 2 (S2). LPA Jensen reviewed medication for resident 3 (R3) and resident 4 (R4). 2 of 2 residents had a medication count under the amount reflected on the Medication Administration Record (MAR). LPA Jensen interviewed S1 and S2 regarding the discrepancy. S1 indicated the facility received the wrong amount of medication from the pharmacy and S2 was unable to explain the discrepancy. The Health and Wellness Director was notified of the discrepancy and she was able to show LPA Jensen that according to the Centrally Stored Medication and Destruction Record (CSMDR) the 2 residents were admitted to the facility with partial prescriptions and all medication was accounted for. In addition, the facility utilizes an electronic Medication Administration Record (MAR). Technical assistance was provided. File Reviews On 11/21/23, LPA Pascua reviewed 7 staff files. 7 of 7 staff files were either missing first aid certifications or the certification was expired. LPA Pascua reviewed 12 resident files, 7 from memory care and 5 from assisted living. 11 of 12 resident files had service need assessments that were either missing or incomplete due to missing signatures. 2 of 12 resident files did not have current Physician Reports. 4 of 11 files did not have a completed property inventory list. LPA Jensen conducted interviews with 3 staff members and 3 residents. Residents interviewed expressed satisfaction with quality of care. Staff interviews revealed opportunity for training enhancement. LPA Jensen requested current copies of: The infection control plan LIC 500 LIC 308 Liability Insurance The documents will be emailed by 12/6/23 Deficiencies are being cited pursuant to the California Code of Regulations (CCR) and/or Health and Safety Code (HSC). Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report, appeal rights and a confidential names list was provided.