Ingleside by the Lake

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Chavez made an unannounced 1-year required annual visit to the facility above. LPA met with Nikole Daugherty, Administrator, and explained the purpose of the visit. LPA requested a staff roster, a resident roster, emergency and disaster plan, and documentation of quarterly emergency drills. Quarterly drills were conducted in December 2022 and March/April 2023. There is no documentation showing they were conducted prior to this. Deficiency cited. LPA toured the facility with the Administrator and the following was noted: LPA observed the license posted, licensing reports, personal rights, non-discrimination notice, LTCO poster, CDSS Complaint Poster, Bill of Rights and Right to Residential Council. The facility has 6 bedrooms and 5 bathrooms, a kitchen, dining room, living room, activity room, and a storage garage. Medications are kept in a locked cabinet in the kitchen. Physical plant was check for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, and all were in good condition. The facility maintains a comfortable temperature. The facility provides a working telephone for resident use. Smoke and carbon monoxide detectors were tested and operational. Fire extinguishers (3) are located in the hall by bedroom 5, at the front entryway, and in the back patio. They were last inspected 4/24/23 and are charged in the green. There are no issues with Fire Clearance. The facility has cameras inside and outside throughout the facility. Living and dining room furniture were also checked for functionality and condition. The living room and dining room are clean, safe and sanitary. Courtyard of the facility has outdoor furniture, with a covered shaded area for residents in the front and back yards. The facility has a fenced swimming pool with locked gates. There is plenty of outdoor lighting available for the safety of the residents. External gates have latches and working properly. Continued on 809-C. Kitchen was sufficiently stocked with two-day perishable and seven-day non-perishables. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. The refrigerator and freezer were in compliance with temperatures. Resident rooms have beds with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and enough lighting for each resident. There is enough linen available to change weekly or more, if need. Bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 112 F and 119 F degrees in resident bathrooms. Residents have a sufficient amount of supplies for personal hygiene. Soap, paper towels and toilet paper are provided by the Licensee. Grab bars are secured in toilet and shower areas. Showers have non-slip bottoms or mats. Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for current Medical Assessments with TB results, Current Appraisal Needs and Service plans, and signed Admission Agreements. Planned activities are offered to residents in care. Resident files reviewed were in compliance. Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations, Health screening with TB results, current First Aid/CPR, and Administrator Certificate. Three out of five staff records reviewed indicate that there is insufficient documentation showing that staff met the minimum hours of required annual training. Deficiency cited. Medications are in a centrally stored and locked room next to the kitchen, including over-the-counter medicines. Medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the residents’ doctor. Proper medication dispensing instructions are followed. The first aid kit has all proper items and is current. Exit interview conducted, deficiencies cited, and the report and appeal rights given.the state’s words, verbatim · CDSS document, May 16, 2023

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Chavez conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Brett Allan, and administrator Zolton Soo. This is a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is a two story with residents residing only the first level and the licensee inhabiting the second level. At 9:18 am, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing the facility for zero (0) non-ambulatory residents; zero (0) ambulatory residents; and, six (6) bedridden residents. The facility has six (6) private resident bedrooms. All resident rooms have direct exits to the outside. The facility has a fire sprinkler system. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is not a staff room as night staff are awake on the NOC shift. All rooms were free of odors. All window screens were clean and maintained in good repair. There is one (1) bathroom in the hallway which is designated as a staff bathroom. Three (3) resident bedrooms have attached bathrooms and there is a hall bathroom designated for Bedrooms #3, 4, and 5. The resident bathrooms have showers with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105*F and 120*F. Continued on 809-C. Resident records are stored in a filing cabinet in the office which is currently located in the kitchen. Staff records are located at Ingleside Assisted Living (facility #405850249) in a locked cabinet in the administrator’s office. Medications are centrally stored in a locked closet in the kitchen. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in a locked closet in the kitchen. Kitchen knives are stored in a locked drawer in the kitchen. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. The trash can is in a cabinet. Kitchen, laundry and house cleaning supplies are stored in the locked kitchen and laundry rooms. The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and family room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is a fireplace in the living room. It is screened and there are no tools. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility has emergency lighting, which included electronic flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There are three (3) fire extinguishers throughout the facility. They are fully charged and do not exceed the expiration date. Continued on 809-C. The laundry area is located outside in a closet in the backyard. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a storage closet in the hallway. Extra incontinence supplies are stored in resident rooms. There is a functioning telephone on the premises in the kitchen, phone number 805-460-6494. The emergency exiting plans/sketch are posted in all hallways and at the entrance. The emergency telephone numbers are posted in the hallways next to the emergency exit plans. Other required postings are posted in the hallway to Bedrooms #3, 4, 5, and 6. The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the front of the facility with tables and chairs where residents can sit. The backyard is fenced and the front yard has parking. There is no gate to the parking area. The backyard is fenced with a locked gate. There is a three-car garage and a shed on the property which are not accessible to residents. There are no items to be corrected prior to licensure. Exit interview conducted and a copy of report emailed to applicant and administrator.the state’s words, verbatim · CDSS document, Jun 2, 2022

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 COMP II Participants: Nikole Daugherty; Kristen Nudo completed comp. II on 4/20/22 for Ingleside Park -405850254 Interview Method: Telephone interview On 05/02/22, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, May 2, 2022