Routine inspection·January 18, 2024

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 receptionist. The Executive Director (ED), Margie Veis met with LPAs 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 10:08 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 and food labels had expiration date clearly marked. 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 tested and operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 01/16/2024. The LPAs observed required postings throughout the common space. The LPAs observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. The last fire inspection was completed on 12/27/2023 and was found to be in compliance with Fire Code Regulations at the time of inspection. Fire and earthquake drills conducted within the last 6 months as per regulation; the last one conducted 12/28/2023. (Report Continued on LIC 809C...) (Report Continued from LIC 809...) BEDROOMS: The LPAs observed three (3) random resident bedrooms in memory care and seven (7) random resident bedrooms in 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. RESTROOMS: The LPAs observed ten (10) random resident restrooms during the inspection. 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 hot water temperature was measured in seven (7) random assisted living bathrooms between 10:20 a.m. and 10:55 a.m., the temperature measured between 112.5 – 115 degrees Fahrenheit. Between 10:00 a.m. and 10:13 a.m., the hot water temperature was measured in three (3) random memory care bathrooms and the temperature measured between 112.7 – 115.3 degrees Fahrenheit. At approximately 10:50 a.m., the LPAs observed the emergency food supply, and a substantial amount of non-perishable items were in poor condition as they were observed past their expiration date. Staff discarded all expired items and ordered new items during the inspection. RECORDS: LPA’s reviewed Resident Records at 11:05 a.m. and Personnel Records at 12:02 p.m. Nine (9) 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. Nine (9) 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. LPAs conducted interviews with six (6) staff and six (6) residents during the inspection. (Report Continued on LIC 809C...) (Report Continued from LIC 809C...) MEDICATIONS: Medications review began at approximately 12:15 p.m. The medications are centrally stored in the medication room on the second floor. 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. 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.