Routine inspection·January 25, 2024

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Administrator Rebecca Rayo, after identifying herself and stating the purpose of the inspection. This facility serves ninety-nine, residents 60 and above; of which twenty-two may be non-ambulatory. A tour of the facility was conducted which included a sample of resident units, the dining area, common gathering areas, and food storage areas. There are no water features on site. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with the required furnishings. Overhead as well bedside lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Showers were equipped with grab bars and non-slip mats. Hot water temperature in residents’ bathrooms were compliant. The facility is operating in accordance with their fire clearance. The smoke and carbon monoxide alarms were present in the building. Emergency lighting, and facility telephone were all working. First aid kit(s) were complete and readily accessible in the medical rooms. Required licensing postings were observed in visible areas of the facility. PPE supplies are onsite. Indoor passageways were free from obstructions. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Some food supplies were kept in in an outdoor locked storage area. Food supply are replenished frequently by outside vendors. Food was observed to be properly labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Centrally stored medications were properly stored and locked in medication carts inside a locked medication room. Medications were labeled and kept in compliance with label instructions. Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPA conducted a review of In-service training procedures. LPA interviewed Administrator Rayo as well as staff and was assured transportation procedures as well as outside medical and dental assistance procedure are compliant. There are two large common rooms used for dining and activities. At the time of visit, LPA observed a few residents participating in a small group activity. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were issued at the time of visit. An exit interview was conducted with Administrator Rayo to whom copies of this report, Licensee/Appeal Rights (LIC9058 03/22), was provided at the conclusion of the visit.