Routine inspection·December 9, 2024

On 12/09/2024 at 12:45 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director (ED), Patti Baird and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of sixty-six (66) non-ambulatory residents. In which, ten (10) residents may be bedridden. Hospice waiver approved for eight (8). Administrator's Certificate #6007608740 expires 01/13/2025. LPA toured the facility with ED including but not limited to two (2) residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 71 (downstairs) and 73 (upstairs) degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 109.5, 109.1, 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LIC809-C Continued... LIC809-C (Page 2) LPA reviewed six (6) residents records. LPA reviewed six (6) staff records and six (6) of six (6) have current first aid training and associated to the facility. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/16/2024: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization Updated LIC 500 Personnel Report LIC 610E Emergency Disaster Plan (Page 9) Copy Certificate of Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.