Routine inspection·July 26, 2024

Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. On today’s visit the LPA met with Onsite Administrator, Diana Ramirez. She was notified of the purpose for the visit. PHYSICAL PLANT: The Licensee appears to be operating the facility within the conditions and limitations specified on the license. Residents appear to be protected against immediate hazards. The interior and exterior areas of the facility were observed to be clean and safe. No pool or body of water was observed on the property. According to the Onsite Administrator, there are no weapons kept on the property. Disinfectants, cleaning solutions, and poisons were inaccessible to residents in care. A comfortable temperature was being maintained in each building on the property. There was sufficient lighting in resident bedrooms to ensure the comfort and safety of residents. Other than seating, each resident bedroom had the required furniture. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. Additional equipment for physically handicapped residents is available. The fire panel was inspected and observed to be in a 'normal' status. Several carbon monoxide detectors were tested throughout the facility and found to be operable. LPA observed missing call buttons for multiple resident bedrooms used for the facility's signal system. The LPA observed no signal system device set up for building two. According to staff, it was unknown where the device was moved to. A citation will be issued. FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. Sufficient supplies for resident's dinning use was observed to be available. RECORD REVIEW: Staff files had required training; including, but not limited to, First Aid/CPR and Suspected Abuse training. Hospice Care Plans were observed on file for residents in care. Staff present had the required criminal record clearances. Admission Agreements, Medical Assessments (Physician's Reports), and Service Plans were observed on file for residents in care. Onsite Administrator Ramirez's Administrator's certificate is currently pending review. Administrator Tracy Langendoen has an active Administrator's certificate. The facility currently has 12 residents in care receiving hospice services; which is within their Hospice Waiver limit. MEDICATION: Two of three medication carts were inspected. Medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be organized, safe, locked, and inaccessible to residents in care. PRN Authorization letters were observed on file. Centrally Stored Medication and Destruction Records were observed on file. This report was reviewed with Onsite Administrator Ramirez and a copy was provided, along with the LIC 811, LIC 9098 and instructions on appeal rights.