Routine inspection·January 23, 2025

Licensing Program Analysts (LPAs) Teresa Camara and Martha Arroyo conducted an unannounced annual inspection. LPAs met with Administrator/Hospital Administrative Resident II (HAR II) Cindy Gambill and Administrator Ray Sena. Entrance interview conducted. Beginning at 9:40 a.m., LPAs started reviewing records. The facility's emergency disaster plan was complete and last reviewed for accuracy by the Administrator on 2/1/2024. The facility conducts evacuation drills quarterly for each shift, the last one was conducted on 10/17/2024. The State Fire Marshall's report was last done on 8/22/2023 and there were no deficiencies. The last sprinkler inspection was done 12/17/2024 with no deficiencies. The annual fire panel inspection was done 3/19/2024 with no deficiencies. The fire doors were inspected 10/11/2024, the fire damper was inspected 9/22/2024, the fire hydrants were inspected 9/24/2024; all had no deficiencies. The facility's liability insurance is up to date with the current policy expiration date as 2/14/2025. Beginning at 11:15, LPAs along with Administrators, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers throughout the facility appeared fully charged and were last inspected 3/28/2024. Fire extinguishers are inspected by staff monthly. RESIDENT ROOMS/RESTROOMS: The facility consists of 36 resident rooms, including both single and double occupancy. Each room contains a restroom. 10 resident rooms and their accompanying restrooms were observed during today's facility tour. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. All resident restrooms observed contained grab bars and non-skid surfaces. Water temperature was measured in various resident restrooms, and measured between 112.8 degrees Fahrenheit to 113.9 degrees Fahrenheit, which is within the required range. KITCHEN: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. LPAs observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day supply of food and water. COMMON AREAS: This includes 2 (two) libraries, a gym, 2 (two) lounges, dining room, spa, laundry rooms, and common restrooms. LPAs observed a fireplace, which was adequately screened, in the dining area. LPAs observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. Other required postings were observed in the common hallways. OUTDOOR SPACE: LPAs and Administrators toured the outside area of the facility. There are various outdoor gardens, a common courtyard, parking areas, as well as multiple shaded seating areas for resident use. All passageways were observed to be clear and free of hazards. RECORD REVIEW: LPAs reviewed records beginning at 12:35 p.m. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All five (5) staff files and five (5) resident files observed were in compliance with regulation except the criminal record clearance for Staff 1 (S1) was not associated to the facility. INFECTION CONTROL: During today’s visit, the LPAs reviewed the facility's Infection Control Plan which appeared adequate. There are hand washing signs posted throughout the facility and hand sanitizer stations throughout the facility. MEDICATION REVIEW: Beginning at 11:45 a.m. LPAs reviewed medications for two residents. The January 2025 centrally stored medication and destruction record (CSMDR) for Resident 1 (R1) in the medication room on the 300 block of rooms was missing. The CSMDR was complete for Resident 2 (R2) in the medication room on the 200 block of rooms. Medications appear to be given as prescribed. INTERVIEWS: During today's visit, LPAs interviewed four (4) staff and four (4) residents. No concerns noted. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC809-D). Exit interview conducted. A copy of today's report was provided.