Routine inspection·April 16, 2024

At 1:45 p.m. on 04/16/24, Licensing Program Analysts (LPAs) Nicholas Reed and Leizl de la Cerra conducted an unannounced annual inspection. LPAs met with staff and disclosed the reason for the visit. LPAs and staff toured the facility inside and out at 1:55 p.m. The facility was last visited on 01/11/2023 for a complaint visit. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents, of which 1 may be bedridden in Bedroom #2. The facility serves residents with dementia. Approved hospice waivers for three (03). LPAs observed a maintained front yard with surveillance cameras at the front. At the main entrance, LPAs observed postings for emergency contacts, confidential complaint contacts, Ombudsman contacts, personal rights, theft and loss policy, administrator certificate, facility sketch with evacuation routes, visitation policy, non-discrimination notice, activity schedule, and COVID postings. LPAs observed a screening station with digital thermometer, visitor log, sanitizer, masks, and additional PPE. Walls, floors, windows, screens, and blinds were clean and in good repair. At 2:00 p.m. LPAs measured the room temperature to be 76 degrees Fahrenheit. Four (04) residents were observed watching television in the living room together. Reading materials, activity books, and games were available near the dining room table. The facility has four (04) bedrooms. One (01) bedroom is designated as a staff room. The staff room was free of hazards. Resident bedrooms were all shared bedrooms. All bedrooms contained a chair, lamp, nightstand, storage, fall prevention mats, and a bed with adequate bedding. All furnishings were clean and in good condition. Bedroom #3 contained a bed with full bed rails. At 3:30 p.m. LPAs checked and confirmed that a physician’s order was present for the full bed rails. The facility has two (02) bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, a bidet, and a non-skid mat in the shower. At approximately 2:10 p.m. LPAs measured the water temperature to be 105.0 degrees Fahrenheit. LPAs observed an adequate supply of perishable and non-perishable and emergency supplies of food in the kitchen. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter. Cleaning solutions were locked below the sink. Medications were locked in a cabinet by the refrigerator. The garage was inaccessible and contained cleaning solutions, extra supplies, an extra refrigerator, and a laundry area. A washing machine and dryer were observed inside. Both were in working order. LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. Ramps were stable with secure handrails. Fruit bearing trees were present in the back yard. The emergency exit path was free from obstructions. The exit gate was unlocked with an inward facing, self-closing latch. Auditory alarms were turned on and functioning. At approximately 3:00 p.m. smoke and carbon monoxide detectors were tested and operational. At approximately 3:10 p.m. LPAs observed a fully charged fire extinguisher in the kitchen. It was last inspected on 08/16/2023. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.