Routine inspection (multi-day)·June 18, 2024

Licensing Program Analysts (LPA) Liliana Silveira conducted an unannounced visit to continue a Required Annual Inspection, which began on 06/17/2024. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Wes Lavender. According to the facility’s license, the facility has a maximum capacity of 175, age 60 and above, 30 of whom may be bedridden on the first floor only. A hospice care waiver is approved for thirty (30) residents. The facility is equipped with delayed egress and secured perimeter in the dementia unit. During today’s inspection, according to records, there were a total of 129 residents in care. During the visits, LPA, accompanied by Building Engineer Mario Castaneda, toured the interior and exterior of the facility and inspected common areas and a sampling of resident bedrooms. LPA privately interviewed multiple staff and residents. LPA also reviewed multiple staff and resident records/files. The files which were reviewed contained the required documents. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained required furniture. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Confidential records and centrally stored medications were kept in locked areas. The facility had at least two days of perishable food and seven days of non-perishable food present. The facility had cooking and dining utensils to facilitate resident meal service. The Walk-In Refrigerator’s temperature was compliant at 40 F, and the Walk-In Freezer’s temperature was complaint at 0 F. The facility’s ambient internal temperature was compliant at 68 F. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Where tested, hot water temperature at taps (which were used by residents for personal care) were compliant: Bedroom #122 sink was 117.8 F, Bedroom #114 sink was 117.1 F, Bedroom #236 sink was 111.8 F, Bedroom #238 sink was 112.5 F, Bedroom #313 sink was 116.1 F. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents diagnosed with Dementia. A pool was present at the facility with secured entrance and a fence at least 5 feet high, which completely surrounds the pool. Per Wes Lavender, no firearms or ammunition are kept at the facility. Smoke and fire alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. Complete first aid kits were present and readily accessible. Licensee presented proof of current/active business liability insurance. Required licensing postings were observed in visible areas of the facility. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Wes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.