Routine inspection·September 7, 2023

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA Flores met with Greg Tillman and explained the reason for the visit. The facility is licensed to serve 15 non-ambulatory adults over the age of 60, with an approve hospice waiver for 2 residents. The facility is in a residential neighborhood and consist of 10 bedrooms, 3 bathrooms in the common areas, rooms #1 - #6 are either single or shared rooms and Rooms #7 - #10 are all single bedrooms with a private bathroom. The Administrator's office is on the second floor, kitchen, living room, dining room, family room, garage/laundry area, a side yard, and a front yard. LPA toured the facility with Greg Tillman and observed the following: Facility is in good repair indoor and outdoor. Kitchen is clean, refrigerator and freezer are in good repair. Sufficient food was observed for at least 2 days of perishables and 7 days of non-perishables. Sharps and medication are kept in the kitchen. Residents do not have access to the kitchen. Each resident's room (8) were observed with sufficient lighting, required furniture, and bedding supplies. Room #3 is being used by staff and room #4 is being used as a storage. Each bathroom (7) was observed in working condition, grab bars and skid mats were observed, and water temperature was tested between 110.1-118.1 degrees F., which is within the required 105-120 degrees F. Cleaning supplies are kept in a lock closet in the hallway. Additional bedding supplies were observed. First aid is available with all the required items. Living room, dining room, and family room are clean and have sufficient seating space. Motion sound detector device was observed in the front door, door going to the laundry, and gate in the side patio. Facility is currently serving 3 residents with dementia. Cameras were observed in the common areas. Carbon Monoxide/Smoke detectors were observed and in working condition. Fire extinguishers were last checked on 7/21/23. LPA checked medication and files for 5 residents. Resident #4(R4) does not have a TB test on file. LPA reviewed 4 staff files, administrator (S1) and staff #5(S5)' files were not available for review. Copies of administrator training were review. No yearly training was available for staff. (CONTINUED ON LIC 809C) LPA reviewed infection control plan and obtained a copy. Emergency disaster plan (LIC610E 10/03) was reviewed. A copy of liability insurance was obtained. Last fire drill was conducted on 3/11/23. LPA interviewed 3 staff and 3 residents. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with assistant administrator and a copy of this report, LIC 809D, and appeal rights were provided.