Routine inspection·January 27, 2025

Licensing Program Analysts (LPAs) Martha Arroyo and Valeria Conway conducted an unannounced annual inspection. Upon arrival, the LPAs met with Executive Director (ED), Margie Veis and explained the reason for the visit. Entrance interview conducted. Beginning at 10:10am, the LPAs started reviewing records which included the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. The last fire safety inspection was completed on 01/15/2025 and was found to be in compliance with Fire Code Regulations at the time of inspections. Emergency disaster drills conducted quarterly as per regulation; the last one being a fire drill on 12/31/2024. Beginning at 11:15am, the LPAs along with the Executive Director, 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 observed: RESIDENT ROOMS/RESTROOMS: The LPAs observed five resident rooms and their accompanying restrooms were observed during today's facility tour. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. The bathrooms were sufficiently stocked with supplies and paper towels. Beginning at 11:30am, the hot water temperature was measured in four assisted living bathrooms and one memory care bathroom, and the temperature measured between 113.4 – 118.4 degrees Fahrenheit. Report Continued on LIC 809C... Report Continued from LIC 809... KITCHEN: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. The LPAs observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day supply of food and water. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. COMMON AREAS: The LPAs observed common areas to be clean and in good condition. The facility maintained a comfortable temperature. Required postings were observed throughout the common space. The LPAs observed stairwells to have emergency evacuation chairs. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced on 1/07/2025. The LPAs observed hand sanitizer stations throughout the facility. OUTDOOR SPACE: The LPAs observed the outdoor garden in Assisted Living and Memory Care which had shaded seating areas for resident use. All passageways were observed to be clear and free of hazards. RECORD REVIEW: The LPAs reviewed resident and staff records beginning at 12:35pm. Ten resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All records were in order. Ten personnel files including the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments with TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. Three out of ten staff files reviewed did not have up to date yearly training and Staff 1 (S1) was fingerprint cleared but not associated to the facility. Report Continued on LIC 809C... Report Continued from LIC 809C... MEDICATION REVIEW: Beginning at 12:00pm, the LPAs reviewed medications for five residents. 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 properly documented on the centrally stored medications and destruction record. Medications appear to be given as prescribed. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC809-D). Exit interview conducted. A copy of report and appeal rights were provided.