Facility Evaluation Report

At approximately 10:00am Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection visit and was greeted by Program Administrator (admin) Shelley Reyes. Facility is a Residential Care Facility for the Elderly (RCFE) with currently one hundred and seven (107) residents in care. Facility has a hospice waiver for twelve (12), a bedridden waiver for thirty (30), and is approved for all non-ambulatory residents.

LPA and admin toured the buildings and grounds. Facility found to be at a comfortable temperature. All passageways and emergency exits were free from obstruction. LPA observed evacuation chairs on both stairways. Admin opened chairs and were observed to be functional. Elevator was operational and functional. Alarm system in exit door heading toward courtyard had minimal low volume, not loud enough to summon staff. Batteries were replaced. In addition, signal system heading toward back parking lot exit next to restrooms was not turned on. (Deficiency cited, see LIC 809D).

Facility's fire extinguishers were observed charged and were last serviced 12/2024. Facility's fire system is hardwired though fire department. Four (4) water heaters throughout facility. Ten (10) residents' apartments were inspected and water temperatures in Residents' bathrooms and communal bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. Residents' bedrooms were inspected and observed to be clean with all the appropriate furnishings. The call system was tested in four (4) resident's rooms. Caregiver response time was 6 minutes and 17 seconds, 1 minute and 33 seconds, 1 minute and 50 seconds and 3 minutes and 50 seconds. Storage rooms containing cleaning supplies and other items that could pose a risk were locked.