Routine inspection·May 30, 2023

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 5/30/2023 at 10:50 a.m. LPA was granted entry and met with Administrator, Garrett Welker, who was informed of the purpose of the visit. At the time of the visit there was (3) staff and (5) residents present. The facility is a two story home with (9) bedrooms and (8) bathrooms and (1) shower room. The facility has an attached garage. The facility has a second floor basement with (3) bedrooms and (1) bathroom, the first floor had (6) bedrooms and (6) bathrooms. No pools or firearms are being kept at the facility. The residents served are elderly ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and client interviews. LPA observed the following: Infection Control: The LPA observed hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients in pantry closet. The smoke detector and carbon monoxide was operational, and the hot water temperature 108F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Care & Supervision / Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator, possesses a current administrator's certificate. Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (4) resident files were reviewed, and possessed all required paperwork. Health Related Services/ Incidental Medical Services: Medication was observed to be locked in a tool chest, however LPA found unlocked medication in the facility activity room for Resident #1 (R1). This deficiency was documented along with plan of correction. LPA reviewed resident medication and found that facility was transferring medication into weekly pill boxes for Resident #2 (R2). This deficiency was documented along with plan of correction. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan which met the department requirements. LPA reviewed documentation showing the facility's last fire drill, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit with all required items. An exit interview was conducted where a copy of this report along with appeal rights and deficiency pages were provided to the Administrator, Garrett Welker.