Routine inspection·March 1, 2022

Licensing Program Analyst (LPA) Maja Jensen called facility prior to arrival at 9:30am to conduct COVID-19 screening questions and confirmed there are no active COVID cases in the facility. Licensing Program Analysts (LPAs) Maja Jensen and Avelina Martinez arrived at the facility unannounced at 9:45am to conduct a reuired 1 year annual visit and met with Administrator Lizeth Guerrero. LPAs explained the purpose of today’s inspection. LPAs were allowed entry into the facility that is licensed to serve a total capacity of 80 non ambulatory residents, today's census is 63, 9 hospice residents in compliance with licensure and fire clearance. 6 of 6 staff observed cleared and associated in Licensing Information System. Administrator certificate expires on 6/19/2022. LPA interacted with a random number of residents during this visit and observed residents engaging in communal dining and activities. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed resident rooms, restrooms, medications room, dining room, communal areas, patio, kitchen, staff offices, and common restrooms. LPA observed facility last conducted disaster drill on 6/30/2021. The temperature inside the facility was measured at 76*F is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30 *F less than the outside temperature. The hot water was measured at 118*F which is not less than 105*F and not more than 120 *F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA reviewed two MAR's to document medications administered per physicians order. The first aid kit was found in compliance containing: a current edition of a first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.