Routine inspection·November 7, 2023

On 11/07/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with caregiver, Billie Darthard and introduced self and stated purpose of the visit. LPA was informed that there are 2 residents in care. The facility has 4 bedrooms, 2 bathrooms, kitchen, 2 dining areas, living room, family room, office, laundry, backyard, and attached garage. LPA completed a walk through of facility and review of records with Administrator, Kelly Evans. 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 74 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 106.4 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, emergency disaster plan, and ombudsman were posted in a common area. LPA observed an outdated emergency disaster plan last reviewed on 10/09/2015. Deficiency issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There was a designated storage space for resident/staff files. Medications was observed locked and inaccessible to residents. There is no swimming pool, bodies of water, firearms 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 residents in care. Dishes, cups, and utensils were also stored properly. Yards/Outside: One shaded patio, side gate with self-latching handle on the left and right side of the house that leads into the backyard. Record Review: LPA reviewed staff and administrator file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed no criminal record clearance for present staff. Deficiency with civil penalty issued. LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed incomplete files for residents. Deficiency issued. LPA observed that the facility did not have an updated infection control plan. Deficiency issued. Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC421BG and appeal rights were discussed and copies were provided to Administrator, Kelly Evans.