Routine inspection·March 26, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the inspection CARE tool. LPA Flores met with Lori Lackey and explained the reason for the visit. The facility is licensed to serve 206 residents over the age of 60 years old of which 171 may be non-ambulatory, 35 bedridden, and a hospice waiver for 20 hospice residents. There are currently 17 residents on hospice. Facility is a two story building in a residential area which consist of shared bedrooms, several common areas, a commercial kitchen, and a courtyard. Facility cares for dementia residents and has delayed egress on exit doors. There is a water feature in the courtyard. The water feature has a fence around the entire perimeter. Facility has a fire sprinkler system throughout the facility. Today's visit consisted of a tour of the facility (Physical Plant Domain) with Lori Lackey and medication review. LPA observed the following: First floor common areas: Lobby, visitation room, dining rooms, activity room all have sufficient space with furniture in good repair, and fireplaces are covered. Commercial kitchen was observed clean, in good repair, and food supplies were observed sufficient for at least 2 days of perishables and 7 days of non-perishables. Seven (7) random bedrooms were observed in the first floor ; each room is furnished with the required furniture, with sufficient lighting, and bedding supplies. Bathrooms were observed in working condition and in room #107 a bottle of disinfectant spray was observed under the bathroom cabinet accessible to the resident. Water temperature was tested between 89.7 - 110.3 degrees F., which is not within the required 105-120 degrees F. (room#114 at 103.8 F., room #119 at 89.7 F., room #134 at 100.5 F.) Second floor: Seven (7) random bedrooms were observed each room is furnished with the required furniture, with sufficient lighting, and bedding supplies. Bathrooms were observed in working condition. Water temperature was tested between 100.4 - 114.4 degrees F., which is not within the required 105-120 degrees F. (room #259 at 100.4 F., room #240 at 104.1 F., room #204 at 90.3 F.)(CONTINUED LIC809C) Second floor: dining room has sufficient furniture and in good repair. Medication room was observed inaccessible to the residents. Each egress system exit door was tested in working condition except for the egress system in the exit gate to the left of the building which exits to El Molino. The gate was observed tied with a rope to hold closed. Medication was reviewed for 14 residents. LPA will return at a different time to continue the annual visit and complete the other domains. Deficiencies were noted during this visit per Title 22 Regulations. Exit interview was conducted with Lori Lackey and a copy of this report, LIC 809D, and appeal rights were provided.