Routine inspection·September 1, 2023

On 9/1/2023 starting at 11:48 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with MaryRose Vinarao, Care Director (CD) and explained the purpose of the visit. The facility’s fire clearance was approved for one-hundred-ten (110) ambulatory residents, which seventy (70) may be non- ambulatory, thirty (30) may be bedridden, and approved for thirty-two (32) hospice residents. Upon entry, LPA observed four (4) staff and eight (8) residents present during inspection. Starting at 12:13 PM, LPA toured facility with CD, including but not limited to eighty (80) bedrooms, eighty (80) bathrooms, kitchen, court yard. The facility consists of 80 total bedrooms which 8 are shared, and seventy-two (72) are private. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents'. The hot water temperature in residents’ common area bathroom was measured at 116.0 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day supply of perishable foods. Sharps and toxins were locked and inaccessible to residents'. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was observed last serviced on 7/25/2023. First aid kit was observed to be complete. Continue on Lic809-C Continued from Lic809 Starting At 1:27 PM, LPA reviewed 10 of 10 staff records. At 2:09 PM, LPA reviewed 10 of 10 residents' records. At 3:39 PM, LPA reviewed a sample of 10 of 10 residents' medications. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 9/8/2023: · LIC 308 Designation of Administrative Responsibility · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan (9 Pages) · Liability Insurance No deficiencies cited during visit. Exit interview conducted with CD, and a copy of this report provided.