Routine inspection·July 7, 2021

Licensing Program Analyst (LPA) Gary Tan met with administrator Angie Heath for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 1:05 PM and the following was noted: There is only one entrance being utilized at the facility and there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPAs were screened upon entry. All staff were observed to be wearing mask upon entrance and during visit. The facility had submitted and approved Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the front and backyard. The facility has sufficient stock of PPE in the storage room. The facility has six (6) bedrooms and three (3) bathrooms currently occupying four (4) residents. Two (2) bedrooms and one (1) bathroom is designated for staff use. The facility is fire cleared for four (4) non-ambulatory residents and has hospice waiver for four (4) residents. (continued on LIC 809) (continued from LIC 809) Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with the family room. The facility maintains a comfortable temperature at 78°F. The smoke and carbon monoxide detector were tested and observed to be operational. The fire extinguisher is located in the kitchen and was last inspected on 05/07/21. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water at the facility. There is a storage facility in the backyard but was locked and inaccessible to client. The garage is attached to the home but locked and inaccessible to residents. It is also being used as the laundry area. Laundry detergents, cleaning solutions and other toxins are stored in the garage. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. All clients' room appeared to be clean and in good repair. Staff Rooms: Staff rooms are locked. No medications are observed in the staff room. The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at 116.2°F. There is enough clean linen available in stock at the linen cabinet. Medications : LPA observed medication in the hallway cabinet to be locked and inaccessible to residents. First aid kit is equipped with necessary tools and supplies. Exit interview conducted and copy of this report issued.