Routine inspection·April 18, 2022

On 04/18/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with administrator Ginger Enriquez. LPA explained the purpose of today’s visit. The facility is licensed for (230) non-ambulatory with (10) who may be bedridden. The facility is licensed for (10) residents on Hospice along with dementia residents in Arbor Hall. The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (35) resident bedrooms in Arbor Unit and (99) resident bedrooms in Assisted Living. Each room has a bathroom in the unit, activity room, dining area, kitchen, and outside patio area. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. A review of Fire Drills was observed to be maintained in order and accurate. The last fire drill was performed on 03/22/22, and a Disaster Drill was conducted on 12/27/21. Several working landline phones are available on-site. A record review of (8) residents' service files was conducted. Evaluation Report continues on LIC 809C DEFICIENCY: During the inspection, LPA observed Room 219 without hot water. The faucet was not working and did not provide hot water. LPA inspected the following rooms: 265, 269, 246, 209, 159, 147, 41, 36, and the men's public restroom on the first floor. In Arbor Hall rooms 5, 23, and 28 were inspected. Faucets used by residents for personal care such as shaving and grooming produced hot water temperature controls at 105 degrees F (41 degrees C) and not more than 120 degrees F (49 degrees C) I NFECTION CONTROL: LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs and COVID vaccinations were conducted. Deficiencies were cited during this inspection visit. An exit interview was conducted and a copy of this report was provided to Ginger Enriquez.