Equinox Care Facility

Type of visit: Required - 1 Year

At approximately 11:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Caregiver Estela Camba and explained the purpose of the visit. Administrator certificate is current. Facility has a Hospice waiver for 3 residents. At approximately 11:45AM, LPA toured the facility to ensure the health and safety of residents in care. The facility was observed to be at a comfortable temperature. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The kitchen equipment was clean and in good repair. Dishware appeared to be stored in a sanitary manner. Food appears to be stored and prepared properly. Refrigerators and freezers were maintained at the proper temperature. Facility has required seven-day non-perishable and two-day perishable supply of food. Emergency food stores and water was present to ensure facility can be self-sufficient for 72 hours. Facility has a generator to supply power in an emergency. Emergency lighting devices were present. First aid kit was present. No pools/bodies of water are on the premises. LPA was not able to find documentation that facility has been conducting Emergency drills every 3 months. At approximately 12:15PM, LPA reviewed 6 staff files. Staff files reviewed did not contain evidence of completed annual training. Three of six files contained current First Aid training. Staff on Duty did not have current CPR certification. All employees requiring background checks are cleared. Continued on LIC809-C… At approximately 1:15PM, LPA reviewed 6 of 9 resident files. All resident files contained the required documentation. Reappraisals were conducted within the last 12 months. Documentation of a physician visit within the last 12 months was present. Hospice care plans were not able to be located. LPA discussed with staff some concerns about diet orders that are not being followed, but there is confusion as to if they are still current. Medication records were organized and contained orders for each medication. There were two PRN authorization letters noting the resident is not able to communicate their need for a PRN and to contact the physician before each dose. There were no records of contacting the Physician. LPA requested Licensee conduct a medication audit to verify PRN orders for each resident. Medications were secured and not accessible. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC610E- Disaster Plan Evidence of Liability Insurance Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Estela Camba and Appeal rights were given.the state’s words, verbatim · CDSS document, Oct 6, 2025

The state marks this report as 8 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

At approximately 11:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to continue the 1 Year required annual inspection. LPA met with Administrator Agnes Ajel and reviewed records. LPA observed 5 staff present during this inspection. LPA reviewed 5 of 5 staff records and found all to contain evidence of required annual training and current first aid/CPR certifications. All other required documents were present. Administrator certificate expired on 11/4/2024 but all required training has been completed and the renewal application has been submitted on time. At approximately 12:00PM, LPA reviewed 6 of 8 resident records and found all to contain the required documents. Care plans have all been updated within the last 12 months. All physician assessments are current. Admission agreements are present and signed by both parties. Residents receiving hospice services have a hospice care plans on file. At approximately 1:00PM, LPA discussed the facilities evacuation plan with the Administrator. Facility will review their procedures and update as needed. No citations issued during today's visit.the state’s words, verbatim · CDSS document, Dec 19, 2024

Type of visit: Required - 1 Year

At approximately 1:15PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Agnes Ajel and explained the purpose of the visit. Administrator certificate is current. LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required seven-day non-perishable and two day perishable supply of food. Medication is locked and not accessible. The facility was observed to be at a comfortable temperature. First aid kit was present. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. Facility has been conducting drills every 3 months. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Evidence of Liability Insurance LPA will return at a later date to review staff and resident records. No citations issued during today's visit.the state’s words, verbatim · CDSS document, Oct 25, 2024

Type of visit: Case Management - Other

At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit to follow up with facility regarding a previous request for a bedridden fire clearance. Prior to this visit, LPA met with the Fire Department to discuss modifications needed prior to the approval of the request. LPA met with Administrator Agnes Ajel and reviewed the items requested by the fire department. Due to the time frames involved for the required additions, Agnes has agreed to retract the request at this time and will resubmit when the additions are complete. The facility, LPA and Fire Department will work together to formulate a plan, with time frames of completion, for the additions needed to allow facility to re-apply for the clearance. The following items will be outlined in the plan: - Integrated fire system, including audio/visual alerts, sprinklers and pull stations - widening of doorways - fire doors - ensuring exit paths are wide enough for emergency personnel These items are not intended to be a complete list of requirements, as there may be more items found that need to be addressed. LPA discussed the facilities disaster plan and disaster drills. The facility has not been compliant with conducting drills as required. LPA requested an updated disaster plan, which describes how facility staff will safely evacuate residents, including bedridden residents, in case of an emergency. LPA provided regulation 87212 and 87606 for review. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Agnes Ajel and Appeal rights were given.the state’s words, verbatim · CDSS document, Jan 19, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(k)(3) · Plan of correction due date: Jan 31, 2024

87705 Care of Persons with Dementia: (k)(3)Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement is not met as evidenced by: Based on interviews conducted, Licensee is not conducting drills as required. This poses a potential Safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 19, 2024

Plan of correction: Licensee will draft an updated disaster plan, which shall provide detail for each item listed in Regulation 87212. In addition, Licensee will train all staff on updated plan and conduct as drill. Written plan and evidence of completed staff training and evidence of completed drill will be submitted to CCL by POC date of 01/31/2024.