Routine inspection·November 2, 2023

Licensing Program Analyst (LPA) Mary Flores and Office Technician (OT) Jade Xu conducted an unannounced annual investigation visit using the CARE inspection tool. LPA met with Nancy Mandic and explained the reason for the visit. Facility is licensed to serve 66 residents over 59 years old of which 26 may be non-ambulatory and 40 may be bedridden. Facility is approved to retain/accept fifteen (15) hospice residents. Facility is a campus area with separate cottage buildings which are identify as the Ranch House (Dementia unit), the Hearth and Stewart Cottage (Assisted Living). LPA, OT, and Nancy Mandic toured the facility and observed the following: The Commons which consist of facility's kitchen, library, and dining area: The kitchen is currently under construction due to plumbing issues which started on September 2023. A temporary trailer kitchen is set up outside the dining area for meal preparation. The trailer has a walking refrigerator and a small freezer which stores food for the 2 days worth of perishables, and the pantry is currently in the administration building which stores 7 days of non-perishables. The dining room and library are clean with sufficient seating area. Upon exiting the building towards the independent living there are two ponds protected by wire over them and a 5ft fenced on the bridge. A fence pool is in the back. The Hearth: Has it's own smaller dining room with a glass screen - fireplace, activities supplies are stored and accessible to resident. Three (3) private bedrooms were observed each have sufficient lighting, furniture, and bedding supplies. Bedroom #3 does not have a bed per residents choice. Bathrooms were observed in working condition, with skid mats/grab bars, and water temperature was tested between 102.7 - 108.6 degrees F., which is not within the required 105-120 degrees F. The Ranch House (Dementia Unit): Has a kitchenette with a small refrigerator for snacks. Drawer was observed with a lock unlock during the visit with a pair of large scissors, and cleaning solution bottle was accessible to the residents next to the microwave. Medication room was locked.(CONTINUED ON LIC 809C) Egress system is in working condition, the building has a fenced patio for outdoor activities with shaded seating area. Dining room is clean and in good repair. Three (3) bedrooms were observed; each room has sufficient furniture, bedding supplies, and lighting. Beds in rooms #3, and #6A were observed to have half bed rails, and bed in room #7B was observed to have a half and a attached rail which make a full bed rail. No physician's request on file for bed rails. Bathroom were observed clean and in working condition, water temperature was tested between 106.1 - 112.1 degrees F. which is within the required 105-120 degrees F. The Steward: It's currently under remodeling which was notified to the department in 2022. It has a clinical room, 3 offices, a medication room, the nurse station has been remove and it will be turn into a seating area. Dining area and kitchenette to prepare snacks. Two (2) bedrooms were observed, both with sufficient lighting, furniture, and bedding supplies. Beds in both rooms have half bed rails. No physician's request on file for bed rails. Room #6 has a half bathroom and room #14 has a full bathroom, both are in working condition, with grab bars, skid was not observed, and water temperature was tested between 109.5 - 109.9 degrees F. A common shower was observed with grab bars, no skid mat was observed. LPA observed construction on the parking lot in front of the The Commons, the Hearth, and the Ranch. Caution tape is placed. Permits were reviewed. This was not notify to the department as of 11/2/23. Fire sprinkle system was observed throughout the buildings. Fire extinguishers were observed throughout and last checked on 12/25/22. Last emergency drill was conducted on 10/18/23. Medication was reviewed for 6 residents. Files were reviewed for 5 residents and 5 staff. Administrator certificate was observed for Deborah Herbert #6003728740 exp. date: 5/2/25. Interviews were conducted with 3 staff and 3 residents. Exit interview was conducted with Deborah Herbert and a copy of this report, LIC 809D, and appeal rights were provided.