Routine inspection·November 6, 2023

Licensing Program Analysts (LPAs) Martha Arroyo and Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 9:40 a.m. Upon arrival, the LPAs were greeted by the front desk staff. The Business Office Manager, Mayra Gutierrez assisted LPA’s shortly after and the reason for the visit was explained. The Interim Executive Director, SanJuana Enriquez arrived during the inspection. Entrance interview conducted. At 10:20 a.m., the LPAs along with staff 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 noted: KITCHEN: The LPAs inspected the kitchen/food service area at 10:30 a.m. Knives are stored and 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. 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. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 05/22/2023. The LPAs observed required postings throughout the common space. The LPAs observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. The LPA’s observed an adequate supply of emergency food and water. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. (Report Continued on LIC 809C...) (Report Continued from LIC 809...) BEDROOMS: The LPAs observed the resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPAs observed a sufficient supply of towels and linens. RESTROOMS: The resident restrooms 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; towels and washcloths are not shared in the private rooms. The hot water temperature was measured in eight (8) random assisted living bathrooms between 10:44 a.m. and 11:26 a.m., the temperature measured between 102.7 – 121.3 degrees Fahrenheit. Between 10:21 a.m. and 10:25 a.m., the hot water temperature was measured in two (2) random memory care bathrooms and the temperature measured between 116.9 – 118.0 degrees Fahrenheit. The water temperature was adjusted at the time of the visit. RECORDS: LPA’s reviewed Resident Records at 11:44 a.m. and Personnel Records at 12:36 p.m. Seven (7) 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. Seven (7) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Out of the seven (7) files reviewed, only one (1) staff had an active first aid/CPR on file. The last fire inspection was completed on 02/20/2022 and was found to be in compliance with Fire Code Regulations at the time of inspection. Staff will have a new inspection scheduled. Fire and earthquake drills conducted within the last 6 months as per regulation; the last one conducted 10/16/2023. (Report Continued on LIC 809C...) (Report Continued from LIC 809C...) MEDICATIONS: Medications review began at approximately 1:15 p.m. The medications are centrally stored in the medication room. Medications are labeled and checked for expiration dates. At 1:46 p.m., record review revealed Resident #1’s (R1’s) medication Lisinoprol’s prescription number on the bottle did not match that on the centrally stored medication and destruction record (CSMDR). Staff corrected prescription number on the CSMDR at the time of the visit. The LPAs conducted interviews with eight (8) staff members and two (2) residents between 12pm and 1pm. During today’s visit, the LPAs obtained copies of the following documents: Census, staff schedule, and limited liability insurance. 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.