Routine inspection·November 17, 2023

Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Administrator, Jack Poyfair, who was informed of the purpose of the visit. The facility is a one story building with locked perimeter, approved for (12) hospice and (6) bedridden. No pools or fire arms are kept at the facility. The facility serves elderly residents ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Infection Control: LPA observed the hand washing stations with hand hygiene supplies and hand washing signs. The facility has a plan on mitigating infectious diseases and training staff. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. Physical Plant: LPA observed the resident bedrooms and bathrooms. Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility was observed to be free of any hazards. Laundry equipment was observed to be in good repair. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature read 118.3F. 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. Record Review and Resident/Staff Files: Two staff files were missing a health screening upon inspection. One staff file was missing current staff training. Deficiencies were cited for these missing files and plan of correction was created with the administrator. Resident files were reviewed and possessed all required paperwork. Health Related Services/ Incidental Medical Services: Resident medication were locked in a medication cart inside a locked medication room. LPA reviewed resident medications for (3) residents 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 last fire drill conducted 11/3/23. Technical advisory note was documented for facility to document required information on future drills. LPA observed all facility exits were clear from obstructions. An exit interview was conducted where a copy of this report, deficiency pages, and appeal rights were provided to Administrator, Jack Poyfair.