Routine inspection·December 31, 2024

On 12/31/2024 at approximately 09:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. Upon arrival LPA was greeted by Caregiver Rachel Langan. LPA stated the reason for their visit. The Facility Representative Glen Hulse arrived shortly after to assist with today’s visit. LPA asked for census, staff, and resident files. LPA conducted a physical plant tour at approximately 10:30 AM and the following was noted: There is only one entrance being utilized at the facility. The facility is a single unit building with four (4) bedrooms and two and a half (2.5) bathrooms currently occupying two (2) residents. No designated staff room. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. Required postings such as See/Say Something, Long-Term Ombudsman, and Resident’s Rights were located alongside entrance. Common areas: Living room and dining room observed to be neat, clean, and organized. Common areas observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 76°F. Fire extinguisher located near the sliding door leading towards the backyard and dated 12/31/24. Electric fireplace observed to be covered and located in the living room inaccessible to residents. Working telephone located in living room. The kitchen observed to be fully stocked with two (2) days perishable and seven (7) days non-perishable food. Kitchen observed to be clean and inaccessible to pests. Knives and sharps observed to be locked in a locked box located on top of kitchen counter and inaccessible to residents. (continued on LIC 809-C) The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. There is no body of water in this facility. Smoke detectors and carbon monoxide observed to be working properly and were tested. Quarterly Emergency drill has not been completed and/or documented. The laundry room is located near the garage. Laundry detergents, cleaning agents, and other toxins are stored within laundry room and are locked inaccessible to residents. Sufficient availability of clean lien stored in laundry room cabinets. The laundry room then leads to a staff office containing resident and staff files kept locked in a filing cabinet. The garage is being used for extra storage, staff break room, and extra supply of cleaning solutions/toxins. The garage can be accessed from inside the facility and kept locked inaccessible to residents. The Residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Residents have sufficient personal hygiene product which is provided by the licensee. The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured at a range of 111.9 - 114.6°F. Towels and washcloths are not shared. Appropriate grab rails and skid mats were observed and in proper condition. Medications: LPA observed medication stored in kitchen cabinet locked and inaccessible to residents. Medication usage recorded and stored properly. LPA along with caregiver Langan conducted a review of the medication to ensure compliance. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer, and manual. Resident records: LPA conducted a complete file review of resident records. Resident records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be incomplete. Administrator and complete staff files missing and/or not readily available for LPA record review. An exit interview was conducted, two (2) citations issued for Personnel Record availability and Emergency Drill not being readily available and/or completed. Appeals rights and a copy of this report was given to Facility Representative Hulse. Administrator and/or Licensee will email LPA Segovia a copy of their complete Personnel Records and Emergency Drill by 1-14-2025.