Routine inspection·January 19, 2024

Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Staff, Karen Vaughan, who was informed of the purpose of the visit. At time of visit there were (6) clients and (3) staff present. The facility is a two story home with the downstairs housing residents, with (4) bedrooms and (3) bathrooms with attached garage. The facility does a pool which has a locked gate surrounding it. No fire arms are kept at the facility. The facility is designated a residential home for the elderly serving elderly 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 in the facility. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has an infection control plan. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The carbon monoxide detector was operation during the time of the visit. The LPA observed video surveillance in the entry way of the facility. The facility does not have signed consent forms or waiver for video surveillance on file with the department. The deficiency was cited and plan of correction was created with staff. 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: LPA reviewed staff files and training that contained staff criminal clearance and updated training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All client medication was locked in laundry room. LPA reviewed client medications and found M1 was not initialed from 1/13 to 1/18, and there was a physician's report and discrepancy on the MARS log for M2 on medication dosage. The deficiency was cited and plan of correction was created with staff. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted October 2023. The staff stated they would conduct a drill by the end of the month. LPA observed all facility exits were clear from obstructions. An exit interview was conducted where a copy of this report along with deficiency page and appeal rights were provided to Staff, Karen Vaughan.