Routine inspection·March 25, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 10:00 AM. LPA met with facility staff who contacted the facility Administrator Anna Lee. The Administrator arrived to the facility at approximately 10:15 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at approximately 10:15 AM the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: OUTDOOR SPACE: The facility has two (2) emergency exit gates located on either side of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed the facility’s outdoor areas to contain cameras. LPA observed the backyard to contain one (1) shed which contained the facility’s emergency water supplies. KITCHEN : The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects. All foods observed were labeled properly and were within their expiration dates. Continued on LIC 809C. COMMON AREAS : This includes the living room, hallway, laundry room, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains a fireplace, it is appropriately screened and contains no tools. Cameras were observed throughout the facility’s hallways and common areas. The hallway was observed to contain a storage closet which contained extra linens for resident use. LPA observed the laundry room to be attached to the facility’s kitchen. The laundry room was observed to contain a pantry, adequate emergency food supplies, and a locked cabinet which contained cleaning supplies and resident medications. The dining area was observed to be equipped with adequate seating for resident use. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms were tested at 11:48 AM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms. BEDROOMS : There are seven (7) bedrooms in the facility; six (6) are single occupancy resident rooms and one (1) is designated as a staff bedroom. LPA and facility administrator toured all six (6) resident bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA observed fall detection devices to be installed in resident rooms. The staff bedroom was observed to be locked and inaccessible to clients in care. BATHROOMS : There are five (5) bathrooms at the facility. three (3) are attached to resident rooms and are designated as private resident bathrooms, and two (2) are designated as a shared/common resident bathrooms. All resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 106.5 and 113.0 degrees Fahrenheit, which is in compliance with regulation. GARAGE: LPA observed the garage to be locked and inaccessible to clients in care. The garage is utilized by facility staff as an office space. Continued on LIC 809C. RECORD REVIEW: Record review began at 10:40 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Three (3) staff files were reviewed. All staff files contained all required documents and trainings. Five (5) resident files were reviewed. All resident files contained all required documentation and signatures. No deficiencies were observed during record review. MEDICATION REVIEW: Medication review began at 11:50 AM. Medications for two (2) of five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 03/03/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator. INTERVIEWS: LPA interviewed three (3) residents. All residents interviewed stated that the staff treat them well and are attentive to their needs. No residents had concerns with the facility. LPA interviewed two (2) staff members. Both staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current liability insurance. No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.