Routine inspection·September 20, 2024

09/20/2024, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 108 residents in care. Facility approved/cleared for 35 non-ambulatory and hospice waiver for 8. At approximately 9:50am, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated. LPA observed an emergency food supply. Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, drawers. LPA observed an area of the facility to be under repair for future memory care use and is inaccessible to residents in care. Facility has scheduled activities for residents in care. Facility has residents with special dietary needs that are noted with resident’s names and their needs in the kitchen. Water temperature in sinks accessible to residents in care were measured at 119.4 and 118.4 degrees, within the range of 105 to 120 degrees F. Fire extinguishers were last inspected January, 2024. Smoke detectors, fire sprinklers, and carbon monoxide detectors located throughout the facility were last inspected June 11th, 2024. Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. At approximately 11:20 am, LPA conducted review of eight staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file. continued on LIC809-C At approximately 12:00 pm, LPA conducted a review of 8 resident records. All records had the required documentation. No deficiencies cited during today's inspection . Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility LIC610- Emergency Disaster Plan LIC9020- Register of Facility Client’s/Resident’s Copy of Certificate of Liability Insurance Exit interview conducted with Administrator and a copy of this report was provided .