Routine inspection·July 17, 2023

On 07/17/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with DHS Jessica Ponce as the purpose of today’s visit was explained. The facility is licensed to serve 120 non- ambulatory residents ages 60 and over and have a hospice waiver for 30. The current census is 86. The facility is a (4) four story structure located in a commercial building in a residential neighborhood. The facility consists of; (110) bedrooms, (71) bathrooms, 1st floor, 2nd floor, 3rd floor, and 4th floor are mirror image of themselves. all the floors contain lounge / movie room, kitchenette, clean linen rooms, mechanical rooms, activities/dining room. activities storage room, wellness room, nursing supplies, laundry chute room. 1st floor has a fireplace in lounge room, shaded side yard with gazebo, plants, and play area, 2nd floor has an incontinence room/staff lounge, and 4th floor has PT/gym room. The basement has (kitchen, laundry room, and PPE storage.) LPA conducted a records review of 8 staff record, 8 resident records and medication Administration Records, LPA did not observe any discrepancies at the time of visit. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire drill was conducted on 05/06/23, fire extinguishers fully charged were observed throughout facility, carbon monoxide detectors observed, smoke detectors are operational, and a landline was observed. All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathrooms were found to be within Title 22 regulation, toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F.. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be locked and inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards. During today’s visit no discrepancies were cited. Exit interview conducted with DHS Jessica Ponce, and a copy of this report was provided.