Routine inspection·October 17, 2024

Unannounced annual visit made out to this facility on 10/17/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated representative, Asha Prasad, who was briefly interviewed. This LPA requested that she go ahead and contact the facility designated Administrator, Andrea Armstrong, to inform her that CCL was present at this time. It was learned that Mrs. Armstrong was unable to be present during today's annual visit. This annual visit was conducted with the facility Business Office Director, Asha Prasad, at this time. Current census was 96 residents. It was learned that there were (6) residents under the care of hospice at this time while (10) other residents were receiving services through home health as well. This facility does have a hospice waiver approved for (15) residents and fire cleared for bedridden and dementia care for residents at any given time. A tour of this facility was conducted. Administrator certificate was observed to be present for facility designated Administrator Andrea Armstrong at this time. Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication rooms, located on each floor, were reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the facility designated medication technicians at this time. The medication carts were observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restroom was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. It was learned that there were several different floor plans for residents on the Assisted Living portion of this facility. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Linen closet, located in the facility laundry area, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time. A tour of the Memory Care portion was conducted. Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 04/18/2024 by the local fire extinguisher company, Alpha Fire Control, and in compliance at this time. First aid kits were observed to be present and contained all of the required components at this time. Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted. A review of (10) facility resident files was conducted. A review of (10) facility personnel files was conducted. The following forms and documents were requested to be updated and submitted into CCL: LIC 308 LIC 400 LIC 500 LIC 610 The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code. Appeal Rights were printed and a copy was given to the facility representative, Asha Prasad, at this time. Exit Interview