Routine inspection·May 9, 2024

Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPAs met with Lynda Whitlock, Receptionist and explained the purpose of the visit. At 9:45am, Administrator, Ian Baker arrived and assisted LPAs with the visit. There are currently thirty five (35) residents 60 years and older residing in the facility. Facility is licensed to serve elderly residents age 60 and above, fire clearance approved for (72) non-ambulatory. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed.  There is a visitor sign-in station located in the main entrance lobby. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility has covid-19 digital signage TV screen above the elevator. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Facility is approved for (10) hospice residents, 87705 compliant. A fire clearance is in place. Fire Drill was last conducted on 3/27/2024. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 10/17/2024. Surety bond in the amount of $65,000 is current and expires 12/01/2024. Physical Plant/Environment Safety: The facility is a 2-story building located in a residential community. The facility consists of: First floor : Lobby, Administrative offices, Conference room, Supply room, Power/Telephone room, Kitchen, Janitor room and Elevator. Second floor: (36) resident bedrooms, Medication room, Library, Staff room, Beauty shop, Doctor's office/Nurse station and Dining room. The interior and exterior physical plant was inspected. Kitchen was inspected, knives, sharps objects, cleaning supplies and toxic substances are inaccessible to residents. Exit doors are free of any obstruction and there are no pools or large bodies of water. The patio furniture in the backyard did not have umbrellas, but there is an area that provide s shade. Laundry area was inspected and one of the washing machines was broken, missing a door. There are cameras without audio in the hallways and common areas. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. LPAs tested hot water temperature in five (5) random resident rooms and water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. Water temperature ranged between 95.3 deg F and 119.8 deg F. : Room #8 - sink faucet broken, dripping hot water only Room #9 - observed insects, drain flies in the bathroom Room #20 - 119.8 deg F Room #23 - 105.2 deg F Room #35 - 95.3 deg F, room has no window covering in the bathroom Room #32 - 101.3 deg F Staffing: A total o f twenty seven (27) staff members incl uding the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records/Staff Training: LPA reviewed four (4) staff files and confirmed health screenings and fingerprint clearances. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator Ian Baker's certificate expires on 01/12/2025. Resident Rights-Information: Resident personal rights are posted. Notice of visiting policy is posted. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. LPAs observed the activities calendar posted in the activity room. The facility has a Resident Council. Facility provides equipment and space to accommodate both outdoor and indoor activities. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Incidental Medical and Dental: Four (4) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. Resident Records/Incident Reports: Resident files are maintained at the facility. A total of four (4) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, medication records, and P & I money records. RCFE complaint poster and Personal rights were observed posted. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Fire drill is conducted on a monthly basis and last fire drill was conducted on 03/13/2024. Residents with Special Health Needs: Half bed rails for mobility assistance were observed in some resident beds. LPAs observed 1/2 bedrail in C2's bedroom and facility cannot provide a written order from C2's physician. "Oxygen In Use" signs were posted on the resident doors who are using oxygen. Deficiencies issued on LIC809-D. An exit interview was conducted, and a copy of this report was provided to Greg Tillman, Administrative Assistant along with the Appeals Rights.