Non-compliance follow-up·August 1, 2023

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management /Non-Compliance visit. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on 10/26/2022. The licensee is placed on frequent monitoring for a period of two years. The LPA met with staff and explained the reason for the visit. The last case management visit was on 05/15/2023. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. Snacks and refreshments are available for residents in the Bistro and dining rooms. Dining room furniture on both floors appeared to be in good condition. There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature. Fire extinguishers were charged and last serviced within the past twelve (12) months. Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging residents in group activities. All activity rooms and common spaces appeared clean and in good repair. The facility has several enclosed courtyards with appropriate outdoor seating for resident use. There were no bodies of water observed. RESIDENT ROOMS: The LPA observed eight (8) rooms, and rooms were furnished with clean linens, furnishings and lighting. Restrooms were observed with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Out of the eight (8) rooms, the LPA found that there were five (5) rooms in which personal care and hygiene items were accessible and unlocked: Room 109, 123, 133, 203, 232. FILES: The LPA reviewed the files of the five (5) resident that had personal care and hygiene items accessible in their rooms. Out of the five (5) files reviewed, the LPA reviewed physician’s reports and identified that there were two (2) residents (Resident #1 – R1, Resident #2 – R2). that are deemed at risk if they have access to personal care items. During the physical plant tour, which took place from 9:35 a.m. – 10:00 a.m., personal care items were accessible and unlocked in the rooms of R1 and R2. The LPA reviewed a selection of staff files to verify adequate training hours as detailed in Health & Safety Code 1569.625. The LPA was unable to confirm the completed hours of the five (5) staff, nor the completed training topics as detailed in regulation. Staff indicated that they verified that care staff completed training through the completion of quizzes, however the quizzes did not detail the number of the hours completed. In addition, the quizzes did not cover all of the topics as required in regulation. INFECTION CONTROL: Upon entry into the facility, the LPA was notified that the facility had three (3) confirmed COVID-19 positive cases as of 07/31/2023. The Executive Director indicated that they would report these cases to the local health department and submit the required incident reports. 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.