Upon arrival, the LPA was greeted by staff and also the Administrator, Rose Anguiano. Reason for the visit was stated. Entrance interview conducted with Administrator - following updated records request were requested and obtained: facility residents and staff roster; fire and smoke alarm tests; dieticians report; facility's current liability insurance; Emergency and disaster plan. Administrator confirmed that they are operating according to the original facility plan of operation submitted and no changes have been made.

The LPA, staff and the Administrator toured the physical plant areas inside and outside to ensure facility is in compliance with Title 22 Regulations. KITCHEN: The LPA began the inspection in the kitchen/food service area at approximately 10:45am; 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. At approximately 11am LPA observed several food items in the refrigerator and freezer not sealed properly and not dated. 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 detectors are tested and maintain operational. The fire extinguishers observed fully charged and were last serviced 10/20/2023. The LPA observed required postings throughout the common space. The LPA observed five (5) stairwells; each have an emergency evacuation chair at the 2nd floor. At approximately 11:35am one stairwell wall was observed in disrepair. RESIDENT BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. At 11:53am, Room 259 window shades observed missing; room 259 and 267 floor tiles missing; Memory Care Hallway floor strips observed peeling off. The LPA did observe resident restrooms stocked with sufficient supply of toiletries; towels and hygiene items. RESTROOMS: Resident restrooms all observed with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and towels ( towels and washcloths are not shared). Room 112 and 212 had very low water flow from the faucet; room 220 restroom observed in unsanitary condition; and restroom drawer observed missing in room 259.

RECORDS: LPA reviewed ten (10) Resident Records at approximately 1:45pm-3pm. 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, personal rights form, preplacement, reappraisal and current needs and services plan. All records were in order.

MEDICATIONS: Medications review began at 3:30pm. The medications are centrally stored in the medication room on the first floor. Medications are labeled and stored inaccessible; medication review revealed that resident medications are not properly documented on the centrally stored medications and destruction log/record. It was revealed that the facility is working with different pharmacies where one pharmacy is providing a printed copy of the centrally stored medication record and others are not. In review of the medication records for random residents it was observed that prescription/non-prescription medications for residents stored at the facility are not recorded on the centrally stored log with all required information (missing expiration dates; fill dates and start dates).

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. 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.

Due to time constraints the annual inspection will continue to a later date. LPA will return at a later date to review staff files and training records.

The following deficiencies observed during today's visit are cited (see 809D) 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.