LPA arrived at 8:20 am, facility looks clean and in good repair and decorated for the Holidays. At 8:35 am LPA requested residents and staff files, at 9:16 am LPA reviewed residents’ files and at 10:21 am LPA reviewed staff files.

At 12:10 pm, LPA and DRS toured the facility, toured the interior and exterior and inspected four residents’ rooms, two cottages, two of the four clinics and two activity rooms as well as a physical inspection of four of the seven floors. During the inspection, LPA measured the water temperature and found that the main building had approved readings of 115 degrees Fahrenheit, but a cottage and one of the dementia care facilities had readings of 128.1 and 126.3 Fahrenheit degrees.

The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linen and hygiene supplies were present at the laundry room, as well as Personal Protective Equipment.

[CONTINUED ON LIC 809-C]

• 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.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days of non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. A pond exists on the premises surrounded by a five foot tall fence. Per DRS, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas.

One deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC809-D page). No Civil Penalty was assessed. Plan of Correction was jointly developed with the staff responsible. An exit interview was conducted with DRS Corinna Norton, to whom a copy of this report, the LIC 809-D pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.