Routine inspection·August 8, 2024

On 8/8/2024, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff. LPA met with Executive Director Lauri Aguilar and Health and Wellness Director Kassandra Hernandez LPA conducted facility tour with Health and Wellness Director. All pathways, entrances and exits were clear from obstructions. The tour started in the facility common areas which were furnished with sufficient seating. The tour continued to the facility kitchen. The kitchen was observed clean, in good repair with necessary items and appliances. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPA toured locked offices and storage rooms. LPA toured several resident rooms which were observed to be furnished with required furniture and adequate lighting. Bathrooms were properly equipped with non-slip mats and grab bars. At 10:01 AM LPA observed laundry detergent, Bleach, and all-purpose cleaner in room #19. LPA observed Fire extinguisher was serviced on 8/15/2023. LPA toured two Locked laundry rooms. Facility cleaning supplies and chemicals are kept locked in hallway closet. Medications are kept locked in the Med Carts in the Medication room. Facility grounds were toured. LPA observed delayed egress doors. Doors and passageways are unobstructed throughout the facility and to the outside. LPA toured an enclosed patio area with sufficient seating and shade for recreational purposes. At 3:02 PM LPA reviewed residents’ medication with MARS and centrally stored list and observed 3 missed medication dosages for two residents. PRN medication was not logged with required information. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. At 4:23PM LPA observed 1 out of 5 staff files were missing Tuberculosis documentation. Staff files were reviewed for good health. It was verified that there are at least two staff on duty who are CPR certified. Continued to next page. Deficiencies are being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. LPA is requesting the following documents be submitted to the Fresno CCL office by 8/15/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020. An exit interview was conducted with Executive Director. Report signed on-site; a copy of this report, 809D with appeal rights was provided. Civil penalty assessed due to repeat citation.