Routine inspection·July 20, 2023

Licensing Program Analysts (LPAs) Martha Arroyo and Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. Upon arrival, the LPAs were greeted by the front desk staff and the Executive Director (ED), Ronda Wilkin arrived shortly after and the reason for the visit was explained. Entrance interview conducted. The LPAs 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 10:16 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 01/19/2023. The LPAs observed required postings throughout the common space. The LPAs observed the stairwells and they each had an emergency evacuation chair. The last earthquake drill took place on 07/18/2023. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. The LPA’s observed an adequate supply of emergency food and water. 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. Report Continued on LIC 809C... Report Continued from LIC 809... 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 six (6) random assisted living bathrooms between 10:48 a.m. and 11:08 a.m., the temperature measured between 107.9 – 117.8 degrees Fahrenheit. Between 10:22 a.m. and 10:42 a.m., the hot water temperature was measured in five (5) random memory care bathrooms and the temperature measured between 105 – 114 degrees Fahrenheit. At 10:27 a.m., the LPA’s observed several items on the counter in Resident #1’s (R1’s) bathroom in Memory Care. Items observed unlocked and accessible to resident included: Gillet shaving cream, Cetaphil skin cleanser, Crest Toothpaste, and an electric shaver. Upon review of R1’s Physician’s Report (LIC 602A) dated 01/17/2023, R1 is at risk if allowed direct access to personal grooming and hygiene items. These items were stored away inaccessible to resident at the time of visit. LPA’s observed trash cans and waste baskets in the memory care unit and hallway restrooms without covers/lids. RECORDS: LPA’s reviewed Resident Records at 11:34 a.m. and Personnel Records at 12:25 p.m. Six (6) 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. Four (4) personnel files and the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Personnel files were printed at the time of visit. All records were in order. MEDICATIONS: Medications review began at 1:25 p.m. The medications are centrally stored in the medication room. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. Report Continued to LIC 809C... Report Continued from LIC 809C... INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are 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 issued.