Routine inspection·November 26, 2024

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with Associate Executive Director Juanita Jackson who was informed of the purpose of the visit. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: 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 and LPA observed the facility courtyard with outdoor furniture and shaded area for residents. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies, detergents, and the sharp and dangerous objects were locked and inaccessible to the residents in care. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector, carbon monoxide, and facility sprinkler system was operational and is maintained annually with the last inspection dated 03/29/2024. Facility kitchen had the ability to prepare food in clean environment. 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 multiple food deliveries a week. LPA observed medication room in Assisted Living was locked and the medication cart lock to be locked and inaccessible to residents in care. MedTechs document medication administration on the facility's electronic Medication Administration Record (eMAR). LPA reviewed four staff files and training. All staff have the required personnel records on file and criminal record clearance, health screening report, and updated training along with CPR/First Aid Certification. Five (5) resident files were reviewed, and possessed all required paperwork which included their Identification Sheet, Consent Forms, Needs and Service Plan, and updated Physician's Report. Facility has an updated emergency and disaster plan and Infection Control plan. LPA observed all facility exits were clear from obstructions. Facility contained multiple charged fire extinguishers located throughout the facility with an inspection date 11/07/2024. Facility conducts disaster/fire drills with the last drill conducted in 10/2024 which met Department Requirements. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Associate Executive Director Jackson.