Routine inspection·June 29, 2021

On 06/29/21, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Executive Director Adrienne Craig-Aziz and explained the purpose of today’s visit. The facility is an RCFE licensed for sixty (60) non-ambulatory and also includes a hospice waiver for (10) ten. Currently, there are (37) non-ambulatory residents residing in the facility, all are over the age of 59 or older. The facility is a three-story structure located in a residential neighborhood. It consists of the following: 40 (92) resident rooms with attached bathrooms, dining area, kitchen, garage, lounge, activity room and roof top shaded area. LPA and executive director toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage area cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Smoke detectors were observed in client rooms and are connected to the fire department. LPA reviewed Medication Administration Record (MAR) and observed it to be maintained in order and accurate During the visit, LPA observed the facility infection control practices. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA reviewed staff and resident temperature and symptom monitoring logs and was shown staff testing for the last couple of months. All mandated inspection control posters were posted. No deficiencies were cited during this inspection visit. An exit interview was conducted, and a copy of this report was provided to Executive Director Adrienne Craig-Aziz.