Routine inspection·January 9, 2024

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 1/9/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with a caregiver and explained the purpose of the visit. Licensee and Admin was present. LPA and caregiver toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, kitchen and dining. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA advised that the rear exit hallway staff area be cleared and that hot water be monitored regularly as temperature was measure at 120' F. LPA reviewed resident files. R1 has an incomplete appraisal. R1 needs a diabetes care plan and staff training. R3 Needs a PRN authorization order. Staff files were reviewed. 1 of 3 staff do not have required training on file. S3 does not have proof of 2023 training on file. LPA requested liability insurance certificate (certificate to be submitted by 11/27/23). As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Exit interview conducted. Report copy and appeal rights provided.