Facility Evaluation Report

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Maninderdeep Kahlon and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 108.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. During the inspection in the kitchen LPA and Administrator observed medications (comfort packs for three residents on hospice) unlocked in the refrigerator. LPA also observed medication errors in the medication administration record for 2 of 2 records reviewed. The facility did not have discontinued medication documentation for R1 from the doctor.

LPA reviewed 3 resident and 2 staff files, including criminal record clearances. All staff are fingerprint cleared, however, S1 was not associated to the facility. Fire drill was completed on 8/2/2021.

Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.