Routine inspection·May 9, 2024

Licensing Program Analyst (LPA) Tuesday Cabiness conducted unannounced Annual Required inspection. LPA entered the facility and observed staff in the common area. LPA informed staff the purpose of the visit, who contacted the Administrator. LPA spoke to Administrator over the phone, who arrived shortly after. LPA checked personnel summary report to verify fingerprint or association clearance, and it was observed all staff is cleared. The facility is licensed to serve for (6) elderly residents, age (60) and over. Currently the facility’s census is (4), with (1) resident on hospice. LPA observed facility license and sketch, emergency disaster plan, grievance/complaint procedures, personal rights, rights of resident council, resident bill of rights, and emergency disaster plan visibly posted the wall; including COVID signs. LPA toured the physical plant inside and outside with staff. LPA inspected resident bedrooms, bathrooms, and common areas, to ensure there were no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility has (6) bedrooms, with (1) room for staff and (2) bathrooms. Inside temperature was comfortable, and LPA observed all areas to be clean and appropriately furnished for resident’s comfort and safety. LPA reviewed the food service and storage area, and it was observed to have a sufficient supply of perishable and nonperishable. The facility stores extra refrigerator in the garage, with fresh fruit, vegetables, and frozen meat. Storage areas for toxins, knives, and medication were locked and secured. Hot water temperature measured at 109.4 degrees Fahrenheit. Bathrooms are provided with soap, towels, non-skid mat, and grab bars were located by shower and toilet. Smoke and carbon monoxide detectors are hard-wired and were operating correctly. Fire extinguishers are fully charged. First aid kit had sufficient supplies including tweezers, scissors, thermometer and first aid manual. The backyard had clear passageways and free from obstruction, with gates easily accessible. Patio furniture area had comfortable table and chairs for residents. LPA checked centrally stored records, and medication records, and observed files had incomplete records and missing information. Resident and staff files reviewed, LPA observed missing training records, incomplete records and documents. This is a potential health and safety risk to residents in care. Citation and technical violations issued; exit interview copy of report, and appeal rights provided.