Routine inspection·February 27, 2025

On 2/27/25 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Cheif Executive Officer (CEO), Roberta "Ro" Linscheid and Licensed Vocational Nurse (LVN), Cecilia Barraza was informed Administrator, Virginia Penner was unavailable. LPA introduced self, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA toured the facility completed. Residents observed in common areas and in rooms. There was 2 resident on hospice at the time of the inspection. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operate on a system. Fire extinguisher last serviced 10/10/24. Last fire drill on 2/24/25. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Sharps, chemicals and medications were located in locked closets/rooms. The following issues were observed during todays visit: Small tear in carpet at doorway of room C-13. Facility sketch missing meeting point. Refrigerator in snack bar in need of cleaning. Bathroom shower in need of cleaning in rooms M-4 and M-7. 2 of 2 Hospice Care Plans observed incomplete. Deficiencies will be cited during annual continuation visit. LPA requested the following documents to be submitted to CCL by 3/6/25: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Personnel Report (LIC 500), Receipt for Liability Insurance coverage, Register of Facility Clients/Residents (LIC 9020) in order to update the facility file. No deficiencies were cited during todays visit. LPA will return at a later date for an annual continuation. Exit interview completed with Licensed Vocational Nurse (LVN), Cecilia Barraza . A copy of this report provided.