Routine inspection·October 30, 2024

On 10/30/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the care tool. LPA met with Executive Director and explained the purpose of the visit. Today's census is 191 residents in care with eight residents on hospice services, facility is licensed for 325, hospice waiver of 20. During today's inspection, LPA and Executive Director conducted a tour of the interior of the facility to ensure health and safety of residents in care. LPA and Executive Director conducted an inspection of facility kitchen, salon, theater room, laundry rooms, library, medication rooms, ten residents room, and the common areas. LPA observed facility to be at a comfortable temperature of 73*. LPA observed facility to have the required posters in the hallway by the common area. LPA observed facility to be clean and sanitary. File review conducted for 12 residents records and 10 personnel records. LPA reviewed Facility's Emergency Disaster Plan 2024 and Elopement and Fire Drills. LPA observed documentation of quarterly drills conducted for 2024. At this time, LPA is requesting a copy of facility's liability insurance to be emailed to LPA by Friday November 8. During room inspections, LPA and Executive Director observed sharps in R1's room. Additionally, LPA was informed if residents in care does not have mild cognitive impairment and/or dementia they are able to store own detergents. This matter will be under review. No deficiencies cited. Exit interview and a copy of the report was provided.