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25 | Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required Annual Visit focusing on COVID-19 Infection Control Practices. LPA was met by Haven Program Manager Daniel Orozco and explained the purpose of the visit. Executive Director Cecilia “CC” Degraff arrived shortly after to assist in the tour. The facility is licensed to serve for a capacity of 106 residents (90 non-ambulatory and 16 Bedridden) ages 60 and above. The facility has an approved Hospice Waiver on file for twenty (20) residents. The Kensington Sierra Madre has an approved Dementia Care Plan in its plan of operation and accepts/cares for residents with dementia. Physical plant was toured and food supply was reviewed. Last fire drill was conducted on 01-10-2023.
LPA OBSERVATIONS:
· The first floor is Assisted Living and consists of 44 resident rooms, lobby/reception area, parlor, art studio/gallery, cinema room, library, dining room, cafe area and main kitchen. The second floor consists of the Memory Care Units, 1) Connections with 24 rooms for residents with mild to moderate dementia and 2) Haven with 21 rooms for late to end stage dementia. Each unit has a dining area, kitchenette , activity area, living room and patio. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. No large bodies of water were observed. There are no security bars or weapons on the premises. The facility has central air and heating accommodations.
· Assisted Living- LPA toured resident rooms 101 and 202. LPA observed each bedroom to contain the required furniture and linens. Each room was observed to have its own bathroom. Bathrooms were observed to be clean and equipped with operational grab bars. The resident rooms have signal systems located in each bathroom and facility phones to call the front desk. The signal system was tested in various locations and is operable. Water temperature in resident room 101 was measured at 105 degrees F which is following Title 22 Regulations. Water temperature in resident room 202 was measured at 105.4 degrees F and is following Title 22 Regulations.
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