Routine inspection·December 5, 2022

Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced required annual visit with a primary focus on Infection Control measures using the CARE Inspection Tools. Upon arrival at the facility, LPA met with Administrator, Sandra Lopez and explained the purpose of this visit. The facility is licensed for 135 non-ambulatory residents age 60 and above. Currently the facility has 115 Residents. Structure The two story residential facility consists of (69) room/ all bedrooms are equipped with full bathroom, Common area includes: front office, TV/ Activity room, activity directors office, dining room, commercial kitchen, medication room, parking lot, laundry rooms, public restrooms, (2) storage rooms, and (1) elevator in the facility, Physical Plant Outside grounds were toured. There are two shaded patio areas available for residents. One is a smoking patio and the other is a nonsmoking. In both patios there are plenty of seating for residents. In the parking area there is a locked shed inaccessible to residents. There were no bodies of water were observed. Walkways around the facility were clear of obstructions or debris. Bedrooms Ten (10) bedrooms were inspected. Beds in shared bedrooms are 6 feet apart/3 feet head-to-toe apart. All shared bedrooms have a privacy curtain between both beds. All bedrooms had the required furniture, including a bed, dresser, nightstand, and chair. LPA observed ample lighting and closet space for residents. All beds had required linens, including mattress cover, fitted sheets, blankets, comforter and pillow. Bathrooms Ten (10) Resident bathrooms were checked, toilets and water faucets worked properly, grab bars were secure. All bathrooms had nonskid mats or nonskid material or a shower chair. The water temperature measured in resident rooms #106 (109.2 degrees F) , #109 (108.4 degrees F), #122 (107.9 degrees F), # 208 (108.9 degrees F), and #227 (109.7 degrees F). Comfortable temperature was maintained in the facility. Kitchen LPA toured the kitchen area and observed a three-day supply of perishable and a seven-day supply of non-perishable food. All appliances were in good working order. All cutleries were in good condition. Knives were inaccessible to residents. LPA Observed the daily menu posted near the dining room. Common spaces LPA walked through all common spaces. The TV/activity room is spacious and can accommodate residents. The dinning room had ample seating for residents. Common areas were clean and clear of hazards; doorways were free of obstructions. There is ample lighting in all common areas. LPA observed the activity board near front office. Laundry Rooms Laundry rooms are kept locked and inaccessible to residents. One laundry room has industrial washer and dryer and is for staff use only. The other laundry room has a washer and dryer and is available to residents upon request if they prefer to launder their own things. Linens & Hygiene LPA observed an ample supply of linens and extra hygiene products. There is an ample supply of individual special care needs (diapers, mats). Medications Centrally stored medications were observed and kept safe and locked and inaccessible to residents. LPA reviewed ten (10) residents medications and matched them to the MARs. Files LPA reviewed ten (10) resident files, they all contained the required documents. LPA reviewed six(6) staff files, they all contained the required documents and continued training. Safety A First Aid kit was inspected and contained all necessary items including an up-to-date manual. There are multiple First Aid Kits throughout the facility. The facility is equipped with multiple Fire Extinguishers fully charged and accessible . The last Fire Drill was on 09/10/22. Smoke detectors and carbon monoxide detectors were in good working order. All necessary signs and exits were posted. Infection Control During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance and visitors log, LPA’s temperature was taken upon entry. LPA observed multiple sanitizing stations throughout the facility. PPE supplies are readily available to staff, and over 30-day supply of PPE. Sufficient paper, cleaning, and disinfecting supplies were observed. All staff were wearing face coverings. LPA observed required postings throughout the facility. LPA reviewed the Liability Insurance which is good through 11/1/23. LPA reviewed the Surety Bond which is good through 1/17/25. No deficiencies were cited. An exit interview was conducted, and a copy of this report to be provided via email.