Routine inspection·August 2, 2024

On 8/2/2024, 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, Amanda Kelsey. LPA toured Front Lounge/seating area and Theater area while waiting for Administrator. LPA conducted the rest of the facility tour with Administrator. All pathways, entrances and exits were clear from obstructions. The tour started in the facility common areas which were furnished with sufficient seating. LPA toured several resident rooms which were observed to be furnished with required furniture and adequate lighting. Bathrooms were properly equipped with non-slip tile and grab bars. At 12:43 PM LPA observed 2 out of 8 rooms had knives. The tour continued to the facility dinning and 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. Medications are kept locked in the Med Carts in the Medication room. Facility grounds were toured. Memory care toured; delayed egress doors observed. 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. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Staff files were reviewed for good health. It was verified that there are at least one staff on duty who are CPR certified. LPA conducted a sample medication audit and observed Resident (R1) had one extra pill in bubble pack that was not given. Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. LPA is requesting the following documents be submitted to the Fresno CCL office by 8/9/2024: 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 Administrator. Report signed on-site; a copy of this report, 809D with appeal rights was provided. Immediate Civil penalties were assessed due to repeat violations.