Routine inspection·November 21, 2022

At 4:05pm, Licensing Program Analyst (LPA) Bennette Pena conducted an annual inspection with the focus of the Infection Control Practice domain. LPA Pena met with the Administrator, Kim Commodore who allowed entry to the facility and explained the purpose of the visit. The facility is licensed to serve the elderly ages 60 and above. First floor only was approved for non-ambulatory. The current census is 48 ambulatory residents, zero (0) non-ambulatory, 26 total number of staff. At 4:20pm, LPA and the Administrator toured the facility and observed/inspected the following: This facility is a 2-story building which consists of 69 rooms, of which 62 room are located in the 1 st floor and 7 rooms in the 2nd floor. Every room is a private room, no shared room The main entrance (front door) is used as the central entry point for everyone. A check in station is set up by the entrance and Covid-19 symptom screening is initiated at entry, where LPA was screened. COVID-19 Infection Control screening protocols and supplies, PPE supplies, and sign-in sheet were observed. COVID-19 signage was placed in several areas of the facility. Lobby, receiving area, dining area, kitchen rooms, living room, dining room, kitchen are all located in the first floor. Staff on duty including the Administrator wore face masks. Facility has 30 days of PPE supplies. PPE supplies are stored in the Emergency Food Storage Room in the 2 nd floor. Knives and other sharp items are stored in the kitchen drawer. The kitchen has 3 entry/exit points which are kept locked at all times. Sufficient food supply of 2-day perishable and 7-day nonperishable were observed. The kitchen has 3 freezers, 2 freezer store the meats and the other freezer stores the vegetables and fruits. The kitchen has a walk in freezer and refrigerator. The fire extinguisher was last inspected on 3/01/22. Hot water temperature was measured in 3 random rooms and read at 108.7 deg F (Room 17), 118.2 deg. F (Room 33) and 106.9 deg F (Room 6), all are within the required range of 105-120 degree Fahrenheit. No deficiencies observed during the time of this visit. The facility is operating within compliance. Exit interview was conducted and a copy of this report was given to the Administrator, Kim Commodore. ***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection.***