Routine inspection·October 20, 2023

Licensing Program Analysts (LPAs) Brian Balisi and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:30am. Upon arrival LPAs met with Administrator Holly Gold and explained the reason for the visit. At approx. 10am  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. Common Areas:  LPAs inspected the common areas throughout the facility. The common areas include two (2) lounges, (2) outdoor patios, Dining room, activity room and book nook. There is a dedicated area for the posting of required documents directly by the Medication room.  The common areas were observed to be  properly furnished and relatively clean at the of the visit.  LPA observed appropriate signage regarding infection control posted throughout the facility.  At the time of the visit, living room and dining room furniture was observed to be in good condition.  The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed throughout the facility,  fully charged and were last serviced May 18, 2023. All exits were observed to  have functioning auditory devices and were operational at the time of the visit. The LPAs observed required postings throughout the common spaces. Bedrooms: At approximately 10:10am,  LPAs inspected (6)  randomly selected bedrooms. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed all bathrooms in each resident bedroom  were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit. At 10:20am LPAs observed multiple personal hygiene items in Room 16 , easily accessible to residents in care. At 10:32am LPAs observed hand lotion in  Room 49., easily accessible to residents in care. Continued from 809 There are 5 shower rooms . LPAs observed shower rooms were clean, sanitary and in operating condition with non-skid surfaces. The shower rooms were sufficiently stocked with supplies of linen and personal hygiene supplies. LPAs observed kitchen was inaccessible to residents in care. Knives are kept inaccessible to residents in care.  Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At approximately  10:17am the LPAs observed non-perishable items in poor condition – Mint Jelly (expired 08/27/2023). LPAs observed staff immediately discard expired items. Dining room furniture were observed to be in good  condition and appeared to be relatively clean. LPAs observed staff cleaning  the dining room.  At approximately 11:45am, LPAs observed residents having lunch in dining room. Records review began at 10:55 am,  six  (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Six (6) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Last emergency disaster  drill was conducted - 8/23/2023 Evacuation Drill Medications review began at approximately 1:30pm The medications are centrally stored in a med room on the first floor. Medications are properly documented on the centrally stored medications and destruction record. 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 and symptoms of Communicable disease. 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 a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate. Continued from 809-C Between 12pm - 1pm the LPAs interviewed  six (6) staff and four  (4) residents. 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 provided