Routine inspection (multi-day)·February 2, 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 Executive Director Rebecca Toves, after identifying herself and stating the purpose of the inspection. This facility serves one hundred fourty five, residents 60 and above. Hospice waiver approved for fifteen. 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 is a water features in the courtyard made inaccessible to residents. 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. 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 each 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. Food supply is 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. Medications were labeled and kept in compliance with label instructions. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPAs conducted a review of In-service training procedures. LPA interviewed Executive Director Toves 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. Staff records review verified that all staff records were not complete and compliant. During today’s visit, LPA file review and staff interview, for 6 of 6 care staff (S1-S6) licensee did not have the required First Aid and/or Cardio Pulmonary Resuscitation (CPR) certificates , which posed a potential safety risk to persons in care. Facility has a two-day supply of perishable food and did not have a seven-day supply of nonperishable food items. Some food supplies were kept in in an locked storage area. During today’s visit, LPA observed storeroom with very limited food supplies. Therefore, did not meet the required one week of nonperishable ‘supplies, which posed a potential health and safety risk to persons in care. During today’s visit LPA toured residents’ rooms and observed some showers did not have non-skid mats or non-skid strips. This poses a safety risk to persons in care. An exit interview was conducted with Executive Director Tover to whom copies of this report, Licensee/Appeal Rights (LIC9058 03/22), and 809-D’s were provided at the conclusion of the visit.