• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

INTERVIEWS: Starting at 9:08 a.m. and throughout the visit three (3) staff including the Administrator and six (6) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit.

KITCHEN: The LPA inspected the kitchen/food service area at 10:32 a.m. the kitchen appeared clean and appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Food is prepared based on the menu. Snacks and beverages are available for residents in the dining area. Knives are stored and inaccessible to residents. Refrigerator and food pantry were checked for proper labels and expiration dates. LPA observed emergency food and water.

LAUNDRY ROOM : LPA observed the locked laundry room adjacent to the kitchen. Laundry room has a washer and dryer and locked cleaning supplies.

SUPPLY CLOSET: LPA observed two (2) locked supply closets containing chemicals, cleaning supplies, and emergency supplies including Personal Protective Equipment (PPE).

BEDROOMS: LPA observed seven (7) randomly selected resident bedrooms, 103, 105, 109, 111, 119, 123 and 125. The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

RESTROOMS: Seven (7) resident restrooms and three (3) community showers appeared clean and observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels ; towels and washcloths are not shared in the private rooms. The hot water measured between 107.2 – 118.6 degrees Fahrenheit all within the required range.

SURROUNDING GROUNDS (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Parking is available for residents and visitors.

Report Continued on LIC 809-C PAGE 3...

RECORDS: Resident Records were reviewed beginning at 11:08 a.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. Personnel Records were reviewed beginning at 12:01 p.m. Six (6) Personnel files including the Administrator’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.

INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control plan, practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard.

MEDICATION AUDIT: LPA conducted a medication review on six (6) randomly selected residents at approx. 1:00 p.m., The medications are centrally stored in the medication room adjacent to the Administrators office. The medication room remains locked at all times. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. During the review LPA observed resident medications to be pre-sorted two (2) days in advance. Administrator was made aware that medication cannot be pre-sorted and of the potential health and safety risk. At the time of the visit the Administrator provided a written statement indicated and confirming their understanding of this regulation, 87465(h)(5) and their intent to abide by it. Administrator will speak to staff about the importance of not pre-sorting medications along with providing a signed statement from all staff. Plan of correction cleared on site.

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. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.