Inspector’s narrative
What the inspector wrote
Licensing Program Analyst (LPA) Michelle Echeverria made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Director of Community Relations, Jennifer Bohner and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) licensed capacity for (70) nonambulatory, hospice waiver for (25), bedridden for (35), fire clearance for delayed egress and locked perimeters and advertising in dementia care. The facility has (3) wings, (39) bedrooms, bathrooms, reception area, living rooms, tv rooms, kitchen, laundry room, staff rooms, offices and shaded patios. LPA was accompanied by Jennifer to conduct a general overall inspection, which included, but was not limited to the following:
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 comfortable temperatures 75, 74, 71, 74, and 76 degrees fahrenheit. Water temperatures measured at 105, 109, 107.4, and 105.9 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating fire extinguishers, smoke detectors, signal alarms and carbon monoxide alarms. Posters such as personal rights, CCL complaint poster, CCL license, ombudsman, and facility sketch were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for residents/staff files. Medications were kept inaccessible to residents. 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. Pesticides and other toxin's are not stored in food areas.
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 residents files for admission agreements, physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medication was audited at random and appeared to be dispensed appropriately by staff. LPA reviewed facility's file for emergency drills, emergency disaster plan, annual fire inspection, and insurance policy.
No deficiencies were cited during this visit. An exit interview was conducted, this report LIC809 and LIC809C were discussed and provided to Director of Community Relations, Jennifer Bohner.
