Routine inspection·June 2, 2023

On 06/02/23, Licensing Program Analysts (LPAs) Antonine Richard and Mario Leon conducted an unannounced annual required, using the full CARE Inspection Tool. LPAs met with Executive Director Remon Pegels 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 thirty eight (38) non-ambulatory residents residing in the facility, all are over the age of 59. The facility is a three-story structure located in a residential neighborhood. It consists of the following: 40 (40) resident rooms with attached bathrooms, dining area, kitchen, garage, lounge, activity room and roof top, with shaded areas featuring table and chairs. 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 for cleaning supplies, toxins, and sharp objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available, maintained properly. The water temperature was measured at 126.8 F in the industrial kitchen, which was not properly identified. Smoke detectors were observed in client rooms and are connected to the fire system. LPA reviewed Medication Administration Record (MAR) and observed it to be maintained in order and accurate. See LIC809C LPAs observed sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Two deficiencies were cited during this inspection visit, see LIC809D. An exit interview was conducted, and a copy of this report and appeal rights were provided to Executive Director, Remon Pagels.