Routine inspection·February 20, 2024

On 02/20/24 Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify administrator of LPA's presence at the facility. Staff called administrator Rebecca Thomas and administrator spoke with LPA via phone. Administrator, Rebecca Thomas arrived at the facility shortly after and assisted LPA with today's visit. LPA and administrator conducted a tour of the facility. Areas toured included but not limited to the kitchen, dining room, residents bedrooms, bathrooms, common areas and backyard. LPA observed sufficient furniture and lighting throughout the facility. LPA observed the facility to have sufficient food supplies for seven (7) day non-perishable and two (2) day perishable. LPA observed toxins, knives and centrally stored medications to be locked and inaccessible to residents in care. All required Licensing posters are present in common area in the facility. The temperature in the facility was 74 degrees. Fire extinguishers was last inspected on 07/25/23. Smoke and carbon monoxide detectors are working and present throughout the facility. First Aid kit is maintained and ready for emergency use. LPA conducted a file review of four (4) resident files . LPA compared medications to those being given for four (4) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). Additionally, LPA reviewed three (3) personnel records which had all required documents. LPA requested a copy of the current liability insurance and LIC500 to be sent to LPA Bains by 03/10/24. LPA completed the full care tool and deficiencies were observed per CCR ,Title 22 Regulations as indicated on 809-D. Exit interview conducted .Appeal Rights and a copy of the report was left at the facility.