At 10:20 a.m., the LPA’s along with the ED and HWD 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 LPA’s inspected the Memory Care kitchen/food service area at 10:20 a.m. and the Assisted Living kitchen/food area at 11:13 a.m. Knives and sharps were stored and inaccessible at the time of the visit. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 11:45 a.m., the LPA’s observed several non-perishables that were expired, these items included two (2) containers of Imperial Apple Juice Concentrate and two (2) cans of Corned Beef Hash (expired – May 2023). Items were discarded at the time of the visit.

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 operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 05/31/2023. The LPA’s observed required postings throughout the common space. The LPA’s observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. The LPA’s observed an adequate supply of emergency food and water.

(Report Continued on LIC 809...)

RESTROOMS: The 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; towels and washcloths are not shared in the private rooms. At 10:28 a.m., the LPA’s observed accessible items inside a memory care bathroom that included a Dove body soap, Herbal Essence Conditioner, Pert Plus Shampoo, and Cetaphil cream. The ED locked the cabinet immediately. The hot water temperature was measured in four (4) random memory care bathrooms between 10:29 a.m. and 10:37 a.m., the temperature measured between 108.9 – 120.2 degrees Fahrenheit. Between 10:47 a.m. and 11:29 a.m., the hot water temperature was measured in nine (9) random assisted living bathrooms and the temperature measured between 108.7 – 122 degrees Fahrenheit. Staff adjusted the water temperature at the time of the visit. The LPA’s observed several resident trash cans and waste baskets without covers/lids. During the walkthrough, the LPA’s observed the facility has trash cans with lids in storage. The ED stated the trash cans will be replaced.

RECORDS: LPA’s reviewed Resident Records at 11:59 a.m. and Personnel Records at 1:15 p.m.

Eight (8) 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.

Eight (8) 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.

The last fire inspection was completed on 08/15/2023 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 08/26/2023.

(Report Continued on LIC 809C...)

At the time of the visit, the LPA’s obtained the following documents: LIC500 Personnel Report, Staff Schedule, Census/Resident Roster, and a copy of the liability insurance.

MEDICATIONS: Medications review began at 1:20 p.m. The medications are centrally stored in the medication room. Medications are labeled and checked for expiration dates. Medications including PRN’s are properly documented on the centrally stored medications and destruction record. The LPA’s observed PRNs to have physicians order on file. No errors observed during the medication 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.