Routine inspection·March 12, 2025

At 9:15 a.m. on 03/12/2025, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the licensee and co-administrator and disclosed the reason for the visit. A file review was conducted prior to this visit. The facility was last visited on 09/20/2024 for a complaint visit. It is a single story building with eight (08) bedrooms, two (02) bathrooms, kitchen, office, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for four (04). At 9:25 a.m. LPA reviewed resident and personnel files. All files were complete and available for audit. The front entrance was gated and unlocked. The front yard was maintained. Once inside, LPA observed postings near the main entrance and the office area for Ombudsman contacts, confidential complaint contacts, facility license, COVID precautions, emergency disaster plan, facility sketch, personal rights, rights of resident councils, and emergency contacts. A screening station at the front contained a visitor log, gloves, masks, and sanitizer. Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:30 a.m. LPA measured the room temperature to be 73 degrees Fahrenheit. The living rooms contained televisions, reading materials, board games, and exercise equipment. A fireplace was appropriately grated with the gas line turned off. Medications, first aid kit, and confidential files were locked near the dining room. Also observed was a sufficient supply of emergency water. The facility has eight (08) bedrooms. The bedroom nearest the main entrance is designated as a staff room. The staff room was locked and free of hazards. It also contained emergency food supplies, PPE, and incontinence supplies. Bedroom #5 was designated for storage and was free of hazards. All resident bedrooms contained a nightstand, storage, and a bed with adequate bedding. All beds with wheels were maintained in the locked position. All furnishings were clean and in good condition. Four (04) out of four (04) bedrooms with oxygen in use had appropriate signage posted on their doors. The facility has 2 bathrooms. Both bathrooms contained liquid soap, paper towels, trash cans with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 10:45 a.m. LPA measured the hot water temperature in Bathroom #1 to be 105.4 degrees Fahrenheit. LPA observed a shaded patio area in the rear of the facility. The patio contained two (02) tables with furniture in good condition. The back yard was maintained with fruit trees and shrubs. Two (02) out of two (02) emergency exit paths were free from obstructions. A shed near the main entrance contained extra supplies. Two (02) out of two (02) auditory alarms were turned on and functioning. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter top. Cleaning solutions were locked in a laundry room adjacent to the kitchen. Also located in the laundry room were a washer and dryer. Both were in working order. At 10:55 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 02/21/2025. At approximately 11:00 a.m. the smoke detector in the hallway was tested and operational. At approximately 11:05 a.m. the carbon monoxide detector in the dining room was tested and operational. LPA, staff, and administrator reviewed resident medications at 11:15 a.m. All medications were maintained in the correct quantities with matching documentation. The house phone was called at 11:30 a.m. and deemed to be operational. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during this visit. Exit interview conducted. Copy of report provided.