Routine inspection·August 24, 2023

At approximately 12:15PM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with Administrator Agnes Ajel. At approximately 12:30PM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure. At approximately 12:45PM, LPA reviewed 5 of 5 resident records. All records contained current and signed admission agreements and current physician reports. Medication records are thorough and contained physician's orders for each resident. 3 residents are receiving Hospice services and the Hospice care plans were up to date for each resident. At approximately 1:30PM, LPA reviewed 3 staff records. All records contained evidence of completed training as required. Evidence of current first aid and CPR training were current. LPA interviewed 2 staff during this inspection. Continued on LIC809-C... At approximately 2:00PM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 8/21/2023. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Evidence of Control of Property Evidence of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.