Routine inspection·September 26, 2023

On 9/26/23 at 10:37 am, Licensing Program Analyst (LPA) Chavez made an unannounced Annual/Required visit to the facility listed above. LPA met with Staff #1 (S1) and explained the purpose of the visit. Approximately 30 minutes later, Victoria Thorne, Administrator, arrived. A tour of the physical plant was assessed, and the following was noted: LPA observed the license posted, Complaint Poster, Bill of Rights and Right to Residential Council, non-discrimination statement, and resident rights in the front entry. Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, all in good condition. The facility maintains a comfortable temperature. The dual smoke detector and carbon monoxide detectors are hard-wired and were tested and operational. Fire extinguishers (2) located in the kitchen and double occupancy bedroom were inspected on 5/5/23 and are charged in the green. There are no issues with Fire Clearance. Living room and dining room furniture were checked and in good condition. The common rooms are clean, safe and sanitary. The courtyards of the facility have outdoor furniture with shaded areas for residents. The kitchen is sufficiently stocked with two-day perishable and seven-day non-perishables. Foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers or are stored in cabinets. The kitchen's stove has knobs (5) attached and the kitchen is accessible to residents in care. Deficiency cited. The kitchen sink’s water temperature was measured at 118 F degrees. Resident rooms are adequately dressed with sheets, pillowcases, mattress pads, and blankets which are in good condition. There is at least one chair, nightstand and sufficient lighting for each resident. There is enough linen available to change regularly. Continued on 809-C. Storage closets have sufficient amounts of personal hygiene products which are provided by the licensee. Bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 118.7 F and 120 F degrees in resident bathrooms. Medications are centrally stored in a locked room in the garage. Medications are properly labeled and checked for expiration dates. A sampling of residents’ medications show they are centrally stored prescription and PRN medication which have been logged in the medications record with proper documentation from the residents’ doctors. Proper medication dispensing instructions are followed and checked for contamination. First Aid kit has all proper items and is current. Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for Medical Assessments, Needs and Service plans, signed Admission Agreements and Pre-appraisals. One out of five resident files reviewed did not contain TB results. Deficiency cited. Two out of five resident files reviewed did not contain Appraisal, Needs, and Services Plans. Deficiency cited. Planned activities are offered to residents in care. Staff records were checked for expired or missing certificates, background clearances, and training: LPA conducted a file review of 5 staff for criminal record clearances/associations and current First Aid. All files are in-compliance. Emergency disaster drills have not been conducted quarterly. The most recent drill was on 1/5/23. Deficiency cited. Exit interview conducted, deficiencies cited, and the report and appeal rights given.