Routine inspection·June 19, 2023

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Brittany Holm, who was informed of the purpose of the visit. At the time of the visit there was (10) staff and (102) residents present. The facility is a two story building with (121) bedrooms and (128) bathrooms, a pool, and two courtyards. The clients served are elderly adults 65 years of age and up. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted staff and client interviews. LPA observed the following: Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. Physical Plant: LPA observed the client bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed the facility pool was surrounded by a locked gate. LPA observed outdoor furniture and shaded area in the courtyard for residents. The LPA observed sharp and dangerous objects are kept locked in the food storage area. Cleaning supplies and other toxins are kept locked in storage closets. Laundry equipment was observed to be in good working condition. The smoke detector and carbon monoxide was operational, and the hot water temperature 119F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA was informed the facility receives 4 food deliveries a week. Care & Supervision / Administration: Adequate staff are present for the supervision of residents during the visit. LPA observed resident # 1 (R1) stuck on the grass making multiple attempts to get back on the sidewalk/path area. R1 was outside in the sun for an unknown amount of time. LPA did not observe any staff during the time and located a staff member to assist R1. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate. Record Review and Resident/Staff Files: LPA reviewed five (5) staff files and training. LPA observed staff member # 1 (S1) was not associated with the facility a civil penalty will be issued. Four of the five staff have criminal clearance and updated training along with CPR/First Aid Certification. Five (5) resident files were reviewed, and possessed all required paperwork. Health Related Services/ Incidental Medical Services: LPA observed medications are kept locked and inaccessible in the medication room. Medications are labeled. LPA observed multiple MedTechs walking with carts supplying the resident's with their afternoon medication. Medtechs document intake on eMARS. LPA reviewed client medications for (5) resident and found all medication listed on MARS and all required labeling was found to be in place. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. An exit interview was conducted where a copy of this report was provided to Administrator, Brittany Holm.