Routine inspection·November 27, 2023

Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Carina Demman. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. Infection Control Plan observed. Operational Requirements: A current Plan of Operation observed. A fire clearance for 6 residents of which (6) may be non ambulatory Hospice care waiver approved for one (1) resident. Physical Plant/Environment Safety: Facility is a single story home consisting of 7 bedrooms (5 resident rooms & 2 staff rooms), 3 bathrooms, living room, family room, dining room, kitchen, laundry room, backyard with shaded patio furniture, and an attached garage The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Staffing: A total of (4) staff members provide supervision to the residents. Sufficient staff observed during visit Continued on LIC 809-C Personnel Records - Staff Training: Administrator on file is current. Staff have criminal background clearance and training. Four (4) staff files were reviewed. Required training observed Resident Records - Incident Reports: A total of Six (6) resident files were reviewed. Required postings observed Resident Rights - Information Required postings observed Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Activities supply observed Food Service: Sanitation practices and kitchen cleanliness was observed. Kitchen has utensils for clients to use and to store their meals Incident Medical and Dental: Emergency transportation available First Aid Kid observed (6) of (6) Resident medications reviewed Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. Residents with Special Health Needs: Needs and Services Plan and Appraisals are on file. Currently (0) residents receiving hospice services. Orders for bed rails on file Inspection Tool was completed and no deficiencies are being cited on todays visit. Exit interview conducted and a copy of this report was provided.