Routine inspection·March 11, 2025

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual inspection visit on 3/11/2025 and was greeted by Administrator Deborah Davis. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected six (6) resident rooms. LPA Ramirez inspected six (6) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Bedroom#2 is currently unoccupied. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). During facility tour, it was revealed resident#1 (R1) was released from skilled nursing on 3/5/2025 with home health wound care. Staff interviews and interview with R1’s responsible party revealed R1 currently has a stage 4 wound on their coccyx. R1 is not on hospice at this time. Per Title 22, Division 6, Chapter 8, Article 11. Health Related Services and Conditions- Prohibited Health Conditions- 87616(a)(1)- Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries . LPA Ramirez will issue a type A deficiency based this observation, and interviews conducted. Administrator agreed to draft a plan what steps the facility will take to address R1’s prohibited health condition. Due to time restraints, LPA Ramirez will return at a later time to complete annual inspection. One (1) violation was cited. A copy of this report, 809-D and appeals rights was provided via email.