Routine inspection·April 29, 2025

Licensing Program Analysts (LPAs) Valeria Conway and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:40 A.M. Upon arrival, the LPAs met with the receptionist, who advised administrator, Monica Reyes of the LPAs presence. Administrator was unavailable during today's visit. Nandita Ashley Kumar, Marketing Director, arrived at 10:10 A.M. and explained that Resident Care Coordinator (RCC), Esmeralda Elizarraraz will be authorized to sign today's reports. At this time, the reason for the visit was explained. Entrance interview conducted. The LPAs conducted a physical plant tour starting at 10:31 A.M along with the RCC and the Marketing Director. The physical plant areas were inspected inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This facility doesn’t have a staff room, facility will provide 24/7 care. The following was observed: BEDROOMS: The facility consists of 106 total bedrooms, of which LPAs observed 15 random resident bedrooms; five (5) in the Meadows (Memory Care) and ten (10) in Assisted Living. All resident rooms observed were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The LPAs checked smoke detectors in the 15-bedroom observed and they were functional at the time of the visit. Continued on LIC 809-C Contined from LIC 809 RESTROOMS : Each resident room contains its own private restroom. Resident restrooms observed contained sufficient grab bars and slip-resistant surfaces. The LPAs conducted an inspection of 5 restrooms in the Meadows and 10 restrooms in the Assisted Living Unit. The LPAs observed that one (1) out of five (5) restrooms did not have toilet paper available. Additionally, 5 out of the 5 restrooms in the Meadows were observed to have paper towel dispensers empty and regular trash cans. LPAs observed used gloves and used incontinence bed pads inside trash cans at the time of the visit. Between 10:44 A.M. and 12:21 P.M. the LPAs measured hot water temperatures in all fifteen (15) restrooms, six (6) out of fifteen (15) restrooms measured above the regulation range of 120 degrees Fahrenheit. COMMON AREAS : Consisting of the lobby, library, activity room, dining room, bistro, and theater room in the Assisted Living side and activity room and dining room in the Meadows side. The LPAs observed common areas to be clean and properly furnished at the time of the visit. The LPAs observed two (2) unlocked drawers in the Meadows common areas with a heavy-duty metal 3-hole puncher, a tape dispenser and two (2) metal staplers accessible to residents in care. Fire extinguishers were observed throughout the facility and were fully charged and last serviced on 02/20/2025. All smoke alarms as well as fire doors and sprinkler system were inspected during the five-year fire inspection which took place on 05/18/2022 and were functional at that time. The combination smoke/carbon monoxide detectors in the hallways were tested and functioned properly. During today’s visit, 5 emergency exits were tested and two (2) out of five (5) required new batteries and the emergency exit leading to staff parking lot was deactivated when tested. RCC activated door immediately and maintenance personnel replaced batteries for the emergency exit for the other two (2) doors. However, the emergency exit on the theater room must be replaced. The temperature was maintained at a comfortable level throughout the building. Cleaning supplies and disinfectants are stored locked per regulation. The LPAs observed cameras in the common areas. The LPAs observed the required postings in the common area. Continued on LIC 809-C Continued from LIC 809-C OUTDOOR SPACE: The LPAs observed the building and grounds in both Assisted Living and Memory Care. Multiple seating areas were observed with tables and chairs and shaded seating areas for resident use. During today’s visit, the LPAs inspected the two (2) side delayed egress doors located in the Meadows. At 11:11 A.M. LPA Conway applied pressure to the egress door from the metal frame and observed the egress door connecting the Meadows to the Assisted Living unit did not secure properly. Additionally, the door failed to trigger the required alarm when opened. RCC called maintenance personnel to check on the door. Maintenance staff stated that the magnet keeping the door shut was out of place and need it to be adjusted. Furthermore, LPAs observed fecal matter through the perimeter of the Meadows’s courtyard, accessible to residents in care. RECORD REVIEW: Between 1:03 P.M. and 3:20 P.M. LPA Arroyo reviewed 8 staff and 8 resident records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisals, and admission agreements. During record review, the LPAs were unable to determine the number of training hours completed per regulation for the past twelve (12) months as training records were unavailable during the inspection for four (4) out of eight (8) staff files. All other staff records reviewed contained all required documentation. Eight (8) out of eight (8) resident files reviewed contained all documents, however, on the appraisal/needs and services plan pages two (2) to five (5) did not contain required information to identify individual needs or to develop a service plan for meeting resident needs. Also, two (2) out of eight (8) forms did not have required signatures from the facility’s representative and resident or resident’s responsible party. Additionally, one (1) out of eight (8) resident files reviewed indicated that resident has no capability for self-care, is not on hospice, and there were no records indicating that an exception request was submitted to the department. Continued on LIC 809-C Continued from LIC 809-C MEDICATION REVIEW: At 2:25 P.M. LPA Conway and RCC conducted a medication review of five (5) residents. Facility documents prescribed medications in the Centrally Stored Medication and Destruction Record (CSMDR). CSMDR lacked a start date. The LPA observed start dates written on the cap of each bottled medication, however, one medication observed did not have a start date and neither Med-Techs present during the inspection or the RCC were aware of medication’s start date on the medication bottle. Additionally, the LPA found discrepancies in five (5) out of five (5) resident’s medication, where the pill counts within bubble packs and the medication bottles did not match the records documented on the CSMDR. Med-Techs on duty were unaware of these discrepancies or how these errors occurred. KITCHEN: The LPAs observed the kitchen/dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food, including emergency supply of food and water. The LPAs inspected food for expiration dates; dates were clearly marked. INFECTION CONTROL: During today’s visit, the LPAs spoke with staff regarding the facility’s infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency drill was documented on 03/21/2025. INTERVIEWS: Throughout today’s visit, LPAs interviewed 4 (four) staff and 4 (four) residents. No concerns noted. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or 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. A repeat violation civil penalty was issued for $1000.00