Routine inspection·April 4, 2024

On 04/04/24, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with staff, Casey Kaler and introduced self and stated purpose of the visit. LPA was informed that there are currently 5 residents in care who are having breakfast in the dining room. The facility has 3 resident bedrooms, 2 resident bathrooms, 1 staff bedroom, kitchen, dining area, living room, 2 activity rooms, attached garage, and backyard with a shed. LPA completed a walk through of facility, review of records and medication audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 70 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 105.2 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the personal rights, ombudsman, complaint poster and emergency disaster plans were posted in a common area. LPA also observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed secured and inaccessible to residents. There are no guns or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service : Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly. LPA observed a lock placed on the refrigerator unable to be opened without a key. Technical violation issued. Yards/Outside: One shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard, and 1 shed used for storage. All outdoor pathways were free of obstructions. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed 5 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were audited at random and appeared to be predispensed by removing the daily dosage from its original container and placing it in a daily container by staff. Technical violation issued. The facility last conducted a fire drill on 02/20/2024. Two technical violations and no deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC9102TV were discussed and copies were provided to the administrator, Brittany Martin who later arrived.