Routine inspection (multi-day)·January 24, 2025

Licensing Program Analyst (LPA), Stephanie Martinez, conducted a continuation of an unannounced required annual inspection at the facility. The LPA met with Executive Director (ED), Brooke Abrego-Huerta, and informed her of the purpose for the visit. Physical Plant / Environmental Safety: The LPA conducted a tour of the facility, accompanied by the facility maintenance director, Sammy Ortiz. The LPA observed the alarm system in all three (3) buildings to show, "system normal". Two (2) carbon monoxide devices were inspected in the two hundred and four hundred halls and observed to be operable. The LPA inspected three (3) bedrooms in both memory care buildings and four bedrooms in the assisted living building. The LPA observed a chair(s) to be missing in room 8 and 27, and 109; a night stand to be missing in room 27; and a drawer to be missing from the chest of drawers in room 22. These violations were addressed at the time of the LPA's visit. Therefore, an advisory notice will be issued. Bedrooms had sufficient lighting for resident needs. Resident bathrooms were observed to have grab bars available and slip resistant material present in the showers. The toilet, handwashing, and bathing facilities were all in working condition. The hot water temperature was tested and observed to be within regulatory requirements. 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. Storage areas were observed to be appropriately secured for the safety of the residents in care. There are no pools or other bodies of water located at the facility. According to ED, Abrego-Huerta, there are no known firearms being stored at the facility. The facility does have a working telephone available for resident use. Staffing: Staff have current First Aid/CPR training on file. Separate staffing is available to perform independent tasks for the operation of the facility. According to ED, Abrego-Huerta, all personnel working in the facility are at least 18 years of age. Emergency training is provided to staff members who work the night shift. ED, Abrego-Huerta, is present at the facility during normal working hours and a manager has been observed to be responsible for the operation of the facility when the ED is temporarily absent. 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 areas in all three (3) buildings and the food supply. 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 posted in the kitchen. There appeared to be at least 7 days worth of non-perishable food items and 2 days worth of perishable food items. 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. Medication rooms were inspected in all three (3) buildings. Centrally stored medications were observed to be organized and inaccessible to unauthorized individuals. Medications were observed to be appropriately labeled. Centrally stored medication and destruction records were observed on file. Resident Records- Incidental Reports: The facility does maintain a continuing record of any illnesses, injury, 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. Admission agreements appeared to meet regulatory requirements. Medical assessments appeared to have all the required medical information. The facility does conduct re-appraisals on residents, and updates are made to resident's written record of care. The facility currently has an approved hospice waiver for twenty (20) residents. There are currently ten (10) residents receiving hospice services. Residents with Special Health Needs : Resident hospice records were observed to have the required records. No smoking - Oxygen in use, signs were observed to be posted throughout the facility. Staff training in oxygen administration was observed to be completed. The facility does have secured perimeters available for residents diagnosed with dementia that wonder. No deficiencies were cited at the time of the visit. This report was reviewed with Executive Director, Brooke Abrego Huerta, and a copy was provided.