Routine inspection·April 2, 2024

Licensing Program Analyst (LPA) Anna Fannell conducted an unannounced visit to this facility for a required annual inspection. Entry into the facility is unobstructed and LPA met with administrator Mayleen Saludez. The facility is approved for a Hospice Waiver for six (6) non-ambulatory residents, on of whom may be bedridden. LPA and Administrator toured the interior and exterior of the facility. Physical Plant: There are no pools or other bodies of water located on the premises. The facility is being maintained at a comfortable temperature for residents. All passageways are kept free of obstruction. Hot water temperature was measured in all bathrooms and measured between 109 and 117 degrees Fahrenheit. Grab bars, textured shower floors, and shower aid equipment are utilized by residents. Fire safety installations such as extinguishers, sprinklers, and alarms are present. Fire extinguishers were observed to be charged and last inspected on 06/27/2023. Bedroom smoke detectors and carbon monoxide detector were tested by Administrator and units were observed working. Overall the facility is in good condition; it is clean, sanitary and free of foul odors. Kitchen and Food Service: LPA was present during lunch service. The facility follows residents' special dietary needs. There is at least a one week supply of nonperishable foods and two days of perishable food items, which meets regulatory requirements. All readily perishable food or beverages capable of micro-organism growth are being stored in covered containers at appropriate temperatures. Sharps and cleaning agents are kept locked and secured. Medication, Care, and Supervision: The facility has sufficient and competent staff to provide services needed to meet resident needs. Chemicals and cleaning agents are stored inaccessible to residents. LPA inspected medications and found them in original containers and appear to be dispensed according to doctors' orders. Resident and Staff Files: LPA reviewed all staff and resident files. Resident files had the required documents including admission's agreement, consent forms, and appraisal and/or needs and services plan. Staff files had the required documentation and training including mandated reporting, health screening report, CPR certification. Operations and Administration: Disaster Plan is present. Administrator is present in the facility a sufficient amount of hours and their administrator certification is up to date. The required ombudsman and licensing posters are posted in public view. Residents rights are posted and a copy is kept the resident's file. During today's visit, LPA Fannell observed two bedridden residents are occupying the bedridden room. This poses an immediate health and safety risks to residents in care. Refer to LIC809D for deficiency cited. Technical advisories were issued to remind staff of current and updated regulations. An exit interview was conducted where this report, LIC 809D, and appeal rights were discussed and provided to Administrator Saludez.