Routine inspection·November 27, 2024

At 11:45 a.m. on 11/26/2024, Licensing Program Analysts (LPAs) Nicholas Reed and Nadia Shahbazian conducted an unannounced annual inspection. LPAs met with staff and disclosed the reason for the visit. LPAs contacted the licensee by telephone at approximately 11:15 a.m. and disclosed the reason for the visit. The facility was last visited on 02/08/2024 for an annual visit. It is a single story building with seven (07) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which six (06) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for four (04). Surveillance cameras are used in common and exterior areas. The main entrance was gated with a doorbell for entry. LPAs observed a maintained front yard and a ramp in good condition leading to the main entrance. Postings at the front included COVID precautions, administrator certificate, facility license, facility sketch, blank copy of the admission agreement, confidential complaints contacts, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights, theft and loss policy, and “No smoking – Oxygen in use” sign. A screening station was located at the main entrance and contained a digital thermometer, visitor log, masks, and sanitizer. Walls, floors, windows, screens, and blinds were clean and in good repair. Three (03) residents were observed in the dining room eating lunch. Two (02) staff members were observed helping residents and preparing lunch. A whiteboard was hung in the living room denoting the date, staff present, and meal times for the day. Board games, puzzles, reading materials, and exercise equipment were provided in the living room. A fireplace was turned off. Medications were locked near the main entrance. Two (02) hallway closets contained extra linens and towels. A locked office in the rear of the facility contained personnel and resident files. The facility has seven (07) bedrooms. One (01) bedroom is designated as a staff room. The staff room was locked and free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. The facility has three (03) bathrooms. One (01) bathroom is private to Bedroom #3, and two (02) are shared. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 12:25 p.m. LPA measured the water temperature in Bathroom #3 to be 116.3 degrees Fahrenheit. LPAs observed adequate supplies of perishable and non-perishable foods in the kitchen. Appliances were in good condition. The stove surface and hood were clean. Sharps and cleaning solutions were locked under the sink. A washing machine and dryer were located in the locked garage. Both were in working order. Detergents, chemicals, and extra supplies were also stored in the garage. LPAs observed two (02) covered patio areas in the rear and side of the facility. The patios contained furniture in good condition. Also observed were potted plants, workout equipment, and a pool which was filled in with cement. All emergency exit paths were free from obstructions. The exit gate was unlocked. Eight (08) out of eight (08) auditory alarms were turned on and functioning. Fire sprinklers were located throughout the facility. At approximately 12:15 p.m. LPAs observed a fully charged fire extinguisher in the kitchen. A complete first aid kit was posted next to the fire extinguisher. At 12:30 p.m. LPAs called the house phone. It was deemed operational. At 1:00 p.m., smoke and carbon monoxide detectors were tested and operational. At 1:10 p.m. LPA reviewed staff and resident files. All files were complete and available for audit. During today's inspection, the facility was in compliance with Title 22 regulations. Exit interview conducted. Copy of report provided.