Routine inspection·January 16, 2025

Licensing Program Analysts (LPAs) Brian Balisi and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at approx  9:45 a.m. Upon arrival, the LPAs were greeted by the front desk receptionist. The Executive Director (ED) Christina Spears, met with LPAs shortly after and LPAs explained the reason for the visit. 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: The LPAs inspected the kitchen/food service area at 10:40 a.m. Knives and other sharp objects 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 and food labels had expiration date clearly marked. At approx. 10:50 a.m. ,the LPAs observed randomly selected resident bedrooms in memory care and assisted living. All resident bedrooms were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPAs observed a sufficient supply of towels and linens. All 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. The water was measured between 105 - 120 degrees Fahrenheit.  At approximately 11:00 a.m., the LPAs observed the emergency food supply, to be sufficient and properly stored in a storage room on the 2nd floor. LPA's observed  furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. Activity Rooms were observed to be clean and well maintained at the time of visit. The fire extinguishers were fully charged and were last serviced 07/18/2024. The LPAs observed required postings throughout the common space. The LPAs observed the stairwells and they each had an emergency evacuation chair. Outdoor areas were observed shaded with sufficient space to conduct activities with furniture suitable for outdoor use. LPAs observed passageways clear of obstruction. There were no bodies of water observed that posed any concern for residents in care. There are detached garages observed for resident's use. LPA observed one (1) garage to store additional furniture, equipment and other supplies for facility use. At approx. 11:40 a.m. LPA’s reviewed Personnel Records and Resident Records. Six (6) 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. All records were in order. 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. The last fire alarm inspection was completed on 07/05/2024 and was found to be in compliance with Fire Code Regulations at the time of inspection. Fire Sprinkler system was last inspected 07/03/2024 and was found to be in compliance with Fire Sprinkler System Code Regulations.  Fire and earthquake drills conducted within the last 6 months. Facility vehicle checklist's were reviewed during the visit. All records were observed to be in order at this time. Medications review began at approximately 12:30 p.m. The medications are centrally stored in med rooms in assisted living and Memory care. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during medications review. 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 at this time. LPA's obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster,  and a copy of the facility’s liability insurance. Interviews were conducted during the visit. Exit interview conducted. A copy of the report was provided to Executive Director.