Routine inspection·July 11, 2023

At 09:10 a.m. Licensing Program Analysts (LPAs) Esther Cortez and Ashley Smith, and Licensing Program Manager (LPM) Desaree Perera arrived at the facility unannounced to conduct a required annual visit. The LPAs were greeted by staff and informed them of the reason for the visit. Administrator Lance Shenk arrived shortly after. At 09:40 a.m. the LPAs and LPM conducted a tour of the physical plant with Administrator Lance Shenk to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double-story residence that consists of two (2) memory care units, and an assisted living unit. The LPAs and LPM observed fire extinguishers throughout the facility, which were fully charged and last serviced 06/27/2023. The Administrator provided an annual fire alarm testing and inspection report done on 3/31/2023 where all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPAs and LPM observed all required postings in the hallway near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen : During the facility tour at 9:43 a.m., the kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents at the bistro. Bedrooms: During today’s visit, the LPA observed ten (10) randomly selected resident units. The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Report will continue on 809-C Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. Out of the ten (10) bathrooms observed, two (2) toilets required cleaning, and the flooring of one (1) bathroom was unclean. Upon observation, staff cleaned the areas. Water temperature measured in the restrooms ranged between 105.8 degrees Fahrenheit and 117.8 degrees Fahrenheit. Common Areas: These included the beauty salon, library, bistro and dining areas in assisted living and memory care units. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. At 9:54 a.m. the LPAs and LPM observed four (4) chairs in poor condition in memory care. The Administrator stated new chairs had been ordered and is waiting for arrival. At 10:07 a.m. the LPAs observed a bug crawling on a door in the hallways of memory care. At 10:45 a.m. the LPAs and LPM observed the beauty salon unlocked with chemicals and cleaning supplies accessible to the residents. The Administrator locked the beauty salon upon observation. An electrical room was observed unlocked by LPA Cortez and LPM. The administrator locked the electrical room upon observation. The facility maintained a comfortable temperature of 75 degrees. There were no obstructions and/or tripping hazards throughout the facility. Surrounding Grounds (Outdoors) : The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both memory care units’ courtyards and the assisted living courtyard. Parking is available for residents and visitors. The LPAs and LPM observed a water fountain with an appropriate amount of water that does not pose a risk for residents. Infection Control: The community's policies and procedures pertaining to infection control were adequate. Record Review: At 01:15 p.m. a review of facility files was initiated. LPA Smith reviewed five (5) of eighty-four (84) resident files. Out of the five files reviewed, LPA Smith identified that one out of five residents (R1) requires an updated physician’s report, due to the diagnosis of dementia. The LPA advised the Administrator to review R1’s file, as other document indicated that R1 had a diagnosis of mild cognitive impairment (MCI). Otherwise, all resident records were in order. LPA Cortez reviewed five (5) staff files. Report will continue on LIC809-C LPA Cortez reviewed five (5) staff files. Out of the files reviewed, the following was noted: One out of five files (S1) only have 3.5 hours out of 40 initial training hours. The LPA was unable to confirm the total four (4) hours of postural support and prohibited health training hours for two out of five files (S2, S3). Otherwise, the staff files were in order. Interviews: During today’s visit, the LPAs conducted four (4) resident interviews and three (3) staff interviews. No concerns voiced during the interviews. Due to time constraints the LPA will return to complete the annual at a later date. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.