Inspector’s narrative
What the inspector wrote
Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection at the facility. The LPA was allowed entrance into the facility and met with Administrator, Kip McMillan, and Wellness Director, Braulio Alberto Gonzalez. They were informed of the purpose for the visit. The inspection included the following:
Infection Control Plan:
The facility has an Infection Control Plan in place. According to Wellness Director Gonzalez, the facility is following the policies listed in the plan whenever there are infectious outbreaks within the facility. Infection Control training was observed to be on file, completed in December 2024, and is ongoing.
Residents are regularly observed for changes in physical, mental, emotional, and social functioning as observed in the facility's Stop and Watch Early Warning Tool.
Operational Requirements:
The facility does have a Plan of Operation available at the facility. Proof of liability insurance was available and had an expiration date of 01/01/2026. The Licensee (
GOLDEN EAGLE SENIOR LIVING,INC.
) is a current and active corporation.
Physical Plant / Environmental Safety:
The LPA conducted a tour of the facility, accompanied Wellness Director, Gonzalez. The LPA observed the buildings alarm panel, located on the first floor, to show, "system normal". Two (2) carbon monoxide devices were inspected on two of three floors and were observed to be operable. The LPA inspected eight (8) resident bedrooms throughout the three (3) assisted living designated floors. The LPA observed some maintenance to be needed, though no immediate health and safety concerns were observed. Bedrooms had sufficient lighting for resident needs. Resident bathrooms were observed to have grab bars available. The toilet, handwashing, and bathing facilities were in working condition. The call system was tested and observed to be in working order. The LPA inspected and observed sufficient space for storage of supplies and equipment. There are no pools or other bodies of water located at the facility. According to Wellness Director, Gonzalez, there are no known firearms
being stored at the facility. The facility does have a working telephone available for resident use.
Staffing:
Separate staffing is available to perform independent tasks for the operation of the facility. According to Wellness Director Gonzalez, all personnel working in the facility are at least 18 years of age. Emergency training is provided to staff members.
Administrator, McMillan, is present at the facility during normal working hours and a manager is available who is responsible for the continued operation of the facility when he is temporarily absent.
Personnel Records-Training:
Three (3) staff members (S7, S8, and S9) present at the facility during the visit were observed to not have fingerprint clearances. A citation and civil penalties will be issued. Training on dementia care, postural supports, restricted health conditions, and hospice was observed on file. Proof of medication training was not available for one (1) staff member (S5). A citation will be issued. Training on resident personal rights and abuse reporting was observed on file.
Resident Rights-Information:
The facility has an internet accessible device available for resident use. The LPA did observe the complaint poster (PUB 475), non-discrimination notice, and Personal Rights signage to be posted throughout the facility.
Planned Activities:
The facility does have activities for residents in care, which include socialization, group discussion, crafts, games, other recreation activities, and outings. The facility does have a staff member who has full responsibility to organize, conduct, and evaluate planned activities. There is sufficient space for activities at the facility.
Food Service:
The LPA inspected the facility's kitchen and dinning areas. The LPA observed all food to be of good quality. All readily perishable foods and beverages capable of supporting rapid and progressive growth of micro-organisms were stored in covered containers at appropriate temperatures. Soaps, detergents, cleaning compounds and similar substances were stored in areas separate from food supplies. All kitchen areas were kept clean and free of litter, rodents, vermin, and insects. Modified diets appear to be provided to residents in care as special diet needs were observed to be noted on an online database utilized by dinning staff.
Incidental Medical and Dental:
The facility is arranging, or assisting in the arrangement of medical and dental care for residents. Staff are assisting residents with the administration of medication. The medication carts (3) were inspected and observed to be organized, secured and labelled appropriately. Centrally stored medication and destruction records were observed on file.
Resident Records/Incidental Reports:
The facility does maintain a continuing record of any illnesses, injuries, or medical or dental care, when it impacts the resident's ability to function or the services needed. Resident records showed pre-admission appraisals, admission agreements, and medical assessments on file. The facility does conduct re-appraisals on residents, and updates are made to resident's written record of care (service plans) as needed. The facility currently has an approved hospice waiver for ten (10) residents. There are currently three (3) residents receiving hospice services. There is currently one (1) resident receiving home health services.
Disaster Preparedness:
The facility does have an emergency and disaster plan in place, which included contact information for appropriate agencies, and other required information. According to Wellness Director Gonzalez, the plan was reviewed within the last year. Proof of staff training on emergency procedures was observed on file. Proof of emergency drills was observed on file; available records showed a
Fire and Earthquake Drill were completed on 11/05/24.
Residents with Special Health Needs
: Resident hospice record (1) was observed to have the required care plan on file. No smoking - Oxygen in use, signs were observed to be posted throughout the facility. Staff training in oxygen administration was observed to be completed.
An exit interview was conducted with Wellness Director, Gonzalez, in which this report was reviewed and a copy was provided, along with instructions on appeal rights and other supplementary documentation. Wellness Director Gonzalez reported he had no questions.
NOTE: The LPA was off the premises from about 12:20 PM to about 12:50 PM.
