Routine inspection·December 10, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Dana Perez and explained the reason for the visit. The facility is licensed to serve 124 non-ambulatory residents over the age of 60, with 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, resident rooms, a medication room, two (2) courtyards, a patio, a smoking area in the first floor. The second floor has a seating area, a TV room, an activity area, several resident rooms. There are a total of three (3) stairwells. The baseman consist of staff offices, a therapy room, a laundry room, a beauty parlor, and staff break rooms. Each resident' room has a private bathroom. LPA conducted a tour of the facility with Dana Perez and observed the following: Facility is clean and in good repair indoor and outdoor. All common areas are in good repair and furnished. Required posters were observed in the hallway across the library. Commercial kitchen was observed clean, and stores sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. A list of special diets is kept in the kitchen. A total of (6) bedrooms were observed each have the required furniture, and bedding supplies, and sufficient lighting. Each resident's bathroom was observed in good repair, with skid strips, and grab bars. Shower's ceiling in room #106 was observed with a crack of about 4in. Water temperature was tested as follow; room #103, tested at 131.0 degrees F., #106 tested at 135.5 degrees F., #207 tested at 132.6 degrees F., #219 tested at 131.3 degrees F., and #226 tested at 135.1 degrees F., which is not within the required 105-120 degrees F. Half bed rails were observed in all (6) bedrooms. Oxygen signs were posted on room #123, oxygen was observed property stored. Courtyards/smoking areas are cleared, a patio with shaded seating area was observed. No large bodies of water were observed. Fire sprinkler system and fire extinguishers were observed throughout the facility. Evacuation chairs were observed in each stairwell. Emergency food supplies and water were observed. Facility maintains a generator in the basement. (CONTINUED ON LIC 809C) LPA reviewed medication and files for 5 residents. Resident #5 did not have a bed rail request on file. Five staff files and training were reviewed. Resident #2 and #4's physician's report note residents have dementia. Per file review residents are not wander risk or non-ambulatory. A change of Administrator has taken place as of 11/4/24. Per current designee documents were mailed to the department. LPA requested that change of administrator documents are submitted to the department by 12/17/24. Infection control plan and emergency disaster plan were reviewed. Last fire drill was conducted on 2/8/24. Deficiencies were noted per Title 22 Regulations. Exit interview was conducted an a copy of this report, LIC 809D, and appeal rights were provided.