Routine inspection·February 28, 2022

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced at 9:20 a.m. for a required one year / post licensing visit. The LPA met with Executive Director Ronda Wilkin and explained the reason for the visit. At 10:57 a.m., 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. COMMON AREAS: The facility is a two-story building. On the first floor, there are the kitchen facilities, dining room, Bistro, laundry rooms, Wellness Center, office spaces, and common restrooms. On the second floor, there is a sensory room, beauty salon, spa, Wellness Center, second floor dining, a private dining space, several activity spaces, office spaces and common restrooms. The LPA observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. There were cameras in the common areas, outdoor courtyard, and exterior perimeter. Required postings were found in the hallway on the first floor. There are fire extinguishers throughout the facility, which were serviced 6/2021. There are three outdoor gated courtyards; two are on the first floor and one is on the 2 nd floor. The LPA observed outdoor furniture, with a covered shaded area for residents. There were no bodies of water observed during today’s visit. Delayed egress was tested on two exits and they were operational at the time of the visit. KITCHEN: The main kitchen is located on the 1st floor. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. Facility uses Sysco Foods for food deliveries, and food delivery takes place twice a week. There was a sufficient supply of perishable and non-perishable food. Food appeared to be of good quality. RESIDENT ROOMS: The LPA observed randomly selected rooms on the first and second floor and no immediate health or safety hazards was observed. Restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Appropriate furniture was also observed in the units. RESIDENT ROOMS: During today's visit, water temperature was tested throughout the units. After a slight adjustment to the water boiler, temperature ranged between 111 – 120 degrees Fahrenheit, which is within the required range per regulation of 105 to 120 degrees Fahrenheit. Appropriate signs promoting good hand hygiene were observed in resident and common restrooms. RECORDS : Resident records were reviewed at 10:30 a.m. The LPA reviewed five files for, but not limited to: admissions agreements, medical assessment, updated appraisals. Out of the five files review, one out of five residents (Resident #1 – R1) was missing a medical assessment. Otherwise, resident records were in order. Personnel records were reviewed at 11:30 a.m. The LPA reviewed personnel records, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification. The Administrator’s Certificate expires 04/20/2023. Out of the five files reviewed, two staff members (Staff #1, Staff #2) require a medical assessment. MEDICATION: Medications review began at 12:05 p.m. The LPA reviewed medications for 2 residents. Medications are maintained locked inaccessible to residents in the Wellness Centers located on the first and second floor. One out of two residents (Resident #2 – R2) has a PRN for Acetaminophen and it was observed that nine out of the thirty pills had been administered. However, staff did not record of the date and times of when the medication was administered. In addition, the medication audit revealed that R2’s Lorazepam is scheduled to be administered at 5 p.m. every day; however, documentation noted that it was administered on 2/26 at 8 a.m., 2/26 at 5 p.m., and 2/28 at 3:48 a.m. INFECTION CONTROL : The facility has a central entry point for symptom screening, temperature checks, and sanitation station. 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 isolate residents if there is a confirmed case of COVID-19. The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The community's policies and procedures pertaining to infection control were 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 provided.