Routine inspection·December 14, 2023

Licensing Program Analyst (LPA) Talwinder Bains arrived on 12/14/23 to conduct the annual inspection. LPA met with Facility staff- Julene Anderson (S1) and explained the purpose of today's visit. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (2) and staff files (2). All residents files have required paperwork. LPA observed incomplete paperwork (LIC503 and TB) for staff (S1,S2) files as mentioned in 809D. LPA and S1 toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Hot water temperature was observed to be 120 degrees F, which is within the regulation range of 105-120 degree. Fire extinguisher was ready for emergency use. LPA audit centrally store log for medications for residents (R1,R2). R2 medication log was found to be accurate. For R1 medication log audit, LPA observed that prescription medications were not matching the dosage, refill dates with original bottle/container and also found 4 PRN medications with expired dates for R1. LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 12/31/23 . Deficiencies are cited on LIC809D per Title 22. Exit interview conducted. Appeal Rights and copy of this report left at facility.