Routine inspection·January 4, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Denise Sutton and explained the reason for the visit. The facility is licensed to serve 60 non-ambulatory residents over the age of 60, of which 5 residents may be bedridden and has a hospice waiver for 9 residents. The facility is located in a residential area and consist of a multi level building with a dining room, library area, a commercial kitchen, courtyard, and patio. LPA conducted a tour of the facility with Denise Sutton and observed the following: Lobby, library, activity room, dining room, and other areas were observed furnished and in good repair. Fireplace in the library was observed covered. Chemical solutions and other harmful liquids were observed locked and inaccessible to residents. Resident's bedrooms (RB) were observed (7 rooms) randomly and each had sufficient lighting, the required furniture and bedding supplies. Each resident's has a personal bathroom which were observed in working condition. Water temperature was tested in each resident's bathroom and measured between 98.8 - 124.0 degrees F., which is not within the required 105-120 degrees F. In RB #222 water temperature tested at 124.0 degrees F., RB#233 tested at 123.4 degrees F., RB 231 tested at 98.8 degrees F., and RB#206 tested at 100.9 degrees F. Carbon Monoxide/Smoke detectors were tested in each room and are in working condition. Fire Extinguishers were observed throughout the building and were last checked on 4/25/23. No large bodies of water were observed. Facility has two courtyards, a smoking patio, and a smaller patio on the side of the building. The courtyard patios were observed with uneven cracks (3) on the ground of about 1.5 - 2ft in length. An emergency evacuation chair was observed on top of the front stairwell. The back stairwell did not have an emergency evacuation chair. LPA reviewed files for 5 residents and 5 staff. Administrator certificate was observed for Denise Sutton #6009562740 exp. date: 3/5/25. LPA will return at a different time to finish the annual visit. Deficiencies noted on LIC 809D per Title 22 Regulations. Exit interview was conducted and a copy of report, LIC 809D, and appeal rights were provided.