Routine inspection·July 21, 2023

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. Upon arrival, the LPA was greeted by staff. The Administrator, Donald Brodt arrived shortly after and the reason for the visit was explained. Entrance interview conducted. The LPA 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. KITCHEN: The LPA began the inspection in the kitchen/food service area at 10:00 a.m. Knives are stored in a drawer next to the oven inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Water temperature was measured in the kitchen sink at it measured at 112.1 degrees Fahrenheit at 10:03 a.m. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature of 75 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and purchased on 07/10/2023. The LPA observed required postings throughout the common space. The last earthquake drill took place on 07/07/2023. Activities were observed in the common areas. Fireplace was observed adequately screened. The LPA observed an adequate supply of emergency food and water. The laundry room is locked and inaccessible. Cleaning supplies and toxins were observed in the laundry room locked and inaccessible. Report Continued on LIC 809C... Report Continued from LIC 809C... RESTROOMS: The resident restroom appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured at110.6 degrees Fahrenheit at 10:19 a.m. At 10:16 a.m., the LPA observed several items in the shower. Items observed unlocked and accessible to resident included: shampoo, conditioner, and body wash. Upon review of R1’s Physician’s Report (LIC 602A) dated 02/23/2023, R1 is at risk if allowed direct access to personal grooming and hygiene items. These items were locked away inaccessible to residents at the time of visit. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. At 10:20 a.m., LPA observed medications and body cleansers in Room #5 accessible to residents in care. Items were immediately locked in the medication’s cabinet. RECORDS: LPA reviewed Resident Records at 10:34 a.m. and Personnel Records at 11:16 a.m. Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Two (2) personnel files and the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. MEDICATIONS: Medications review began at 1:55 p.m. The medications are locked in a cabinet inside the office. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. Report Continued on LIC 809C... Report Continued from LIC 809C... INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promote good hand hygiene. The facility has an adequate supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued.