Facility Evaluation Report

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Legal/Non-compliance visit and met with Administrator (ADM) Samuel Apostol.

The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on February 8, 2024.

During visit, LPA Marrufo toured the facility hallways, common areas, resident bedrooms, bathrooms, and outdoor areas. One bedroom was undergoing renovations during visit. ADM stated that the facility has received a grant and is renovating each room one at a time.

All fire exit routes were free and clear of obstruction. LPA observed signs posted next to the resident bedroom doors for the residents who are a fall risk. Fly traps were observed next to exit doors, inside the resident bedrooms, smoking areas, common areas, and hallways. The facility protocol for contacting 911 and signs instructing staff what to do if a resident has a fall were posted throughout the facility.

LPA randomly reviewed 3 resident files, which included but were not limited to: physicians report, needs and services plan, and admission agreement. 3 staff files were randomly reviewed and the staff training files were up-to-date. LPA observed facility maintenance log. LPA observed the fall risk log is completed daily and every 2 hours, which contains the list of residents who are a fall risk and incontinent.

No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of this report was provided.