Routine inspection·October 10, 2022

On 10/10/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA Han was properly screened for COVID-19 by the receptionist at front entrance. After the screening, LPA was greeted by the Administrator, Alan Fox and LPA explained the purpose of the visit. LPA reviewed the following documents: daily monitoring and screening documents for residents, staff and visitors, and Infection Control training records. LPA toured the facility and observed COVID-19 signs posted throughout the facility. The public bathrooms on 1st floor have hand-washing signs posted, foot operated lids, equipped with motion censor paper towel and liquid soap dispensers. There are hand sanitizer dispensers installed throughout the facility. LPA toured 3 memory care neighborhoods and observed chemicals are locked in a designated room, each memory care neighborhood and its own medication room and were observed to be locked, the trash can have foot operated lids, and dining room tables were 6" apart. Facility has dedicated one apartment for PPE and cleaning supplies storage for at least 30 days. Inside this apartment, LPA observed donning and doffing signs, isolation carts, inventory sign-out sheets and cleaning supplies. According to the administrator, facility conducts inventory orders on a monthly basis. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. The kitchen appeared to be cleaned and tidy. there are 3 hand washing sinks with hand washing instruction posted. LPA observed the temperature for the refrigerator was measured at 38 degrees Fahrenheit (F) and the freezer was measured at -10 degrees F. LPA toured the 2nd floor nursing station in a locked room and observed First Aid Kits were equipped and the medication carts were locked. Overall, the facility appeared to be cleaned and tidy, toxins and sharps are stored appropriately and inaccessible to residents. A comfortable temperature is maintained, lighting is sufficient for comfort and safety. During today's visit- LPA requested for a copy of the LIC610E (Emergency Disaster Plan) to be submitted to CCL by 10/13/2022. No deficiency cited today. This report is reviewed and discussed with the Administrator. A copy of this report is provided.