Routine inspection·December 27, 2024

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual inspection utilizing the CARE tool. LPA met with co-Administrator and explained the purpose of the visit. Administrator arrived shortly to the facility. Today's census is six residents in care with three residents on hospice services, Facility is licensed for six non-ambulatory residents, hospice waiver of four. Facility is in compliance to licensure. LPA and Administrator discussed possibly increasing facility hospice waiver. LPA provided Administrator a copy of CCR 87632 Hospice Care Waiver. During today's inspection, LPA and co-Administrator conducted a tour of the facility to ensure the health and safety of residents in care. LPA observed the facility to have the required CCLD poster and Long Term Care Ombudsman poster posted in a conspicuous space. LPA observed facility to be at a comfortable temperature of 76*. LPA observed the presence of two days of perishable and seven days of nonperishable foods. LPA observed fire extinguisher to be recently serviced on October 21, 2024. LPA observed facility to have audio alerts on exit doors, LPA was informed facility does not have any exit seekers and that alerts are disabled during active hours when home health and hospice agencies are visiting. LPA observed resident rooms to be free of sharps, toxins and medications. LPA conducted a file review and observed facility to have quarterly fire drill training documented for the year of 2024. LPA observed facility to have documentation of active liability insurance. Emergency Disaster Plan was present and recently updated on October 8, 2024 by Administrator and co-Administrator. File review conducted for six residents in care and observed the required documents present and completed. Inspection tool was completed and found facility to be in substantial compliance. No deficiencies cited. Exit interview conducted and a copy of the report was provided.