Routine inspection·July 5, 2023

Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection in conjunction with a complaint visit at 10:07 am. LPA conducted a tour of the physical plant at approximately 11:25 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility has two (2) floors. The first floor contains resident rooms, Staff access only kitchen, dining room, great room, and furnished patio. The second floor contains resident rooms, theater, beauty salon, furnished veranda patio, medication room, and activity room. Floors are accessible by elevator and stair access. Common areas were observed for the ability to safely serve the needs of residents. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents, clean and free from odors. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the forty-nine (49) residents currently residing there. Two (2) days of perishable food 7 days non-perishable food observed. The freezer and pantry rooms were stocked with meats and frozen vegetables. Sharps are stored in the locked kitchen area. Laundry room in hallway across from the kitchen. The appliances observed to be functional. Toxins stored in locked closets observed to be locked and inaccessible to residents. Medications are stored in two (2) locked medication carts and/are in the medication room. (Cont from 809) The facility has a capacity of 90. A random sample of six (6) bedrooms private rooms with a private bathroom were inspected. Resident bathrooms were inspected and observed for compliance. Each bathroom had the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for the six (6) bathrooms to ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 108.0 and 113.4-degrees Fahrenheit. There are approximately six (6) fire extinguishers located throughout the facility. Each fire extinguisher observed to be attached to walls, charged, and stored with a flashlight. Smoke detectors/carbon monoxide detector were tested and operable at time of visit. Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection. At approximately 1:10 pm, LPA reviewed a total of 10 (ten) random files: six (6) resident and four (4) staff files. Resident files included physicians’ assessment, services appraisals, admission agreements, and personal rights documentation. Staff files had current CPR/First aid including appropriate medication and caregiver training's. LPA to return at a later time to complete staff and resident interviews as part of the annual inspection. Exit interview conducted/ Copy of report emailed.