Routine inspection·May 16, 2023

Licensing Program Analyst (LPA) Chavez made an unannounced 1-year required annual visit to the facility above. LPA met with Nikole Daugherty, Administrator, and explained the purpose of the visit. LPA requested a staff roster, a resident roster, emergency and disaster plan, and documentation of quarterly emergency drills. Quarterly drills were conducted in December 2022 and March/April 2023. There is no documentation showing they were conducted prior to this. Deficiency cited. LPA toured the facility with the Administrator and the following was noted: LPA observed the license posted, licensing reports, personal rights, non-discrimination notice, LTCO poster, CDSS Complaint Poster, Bill of Rights and Right to Residential Council . The facility has 6 bedrooms and 5 bathrooms, a kitchen, dining room, living room, activity room, and a storage garage. Medications are kept in a locked cabinet in the kitchen. Physical plant was check for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, and all were in good condition. The facility maintains a comfortable temperature. The facility provides a working telephone for resident use. Smoke and carbon monoxide detectors were tested and operational. Fire extinguishers (3) are located in the hall by bedroom 5, at the front entryway, and in the back patio. They were last inspected 4/24/23 and are charged in the green. There are no issues with Fire Clearance. The facility has cameras inside and outside throughout the facility. Living and dining room furniture were also checked for functionality and condition. The living room and dining room are clean, safe and sanitary. Courtyard of the facility has outdoor furniture, with a covered shaded area for residents in the front and back yards. The facility has a fenced swimming pool with locked gates. There is plenty of outdoor lighting available for the safety of the residents. External gates have latches and working properly. Continued on 809-C. Kitchen was sufficiently stocked with two-day perishable and seven-day non-perishables. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. The refrigerator and freezer were in compliance with temperatures. Resident rooms have beds with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and enough lighting for each resident. There is enough linen available to change weekly or more, if need. Bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 112 F and 119 F degrees in resident bathrooms. Residents have a sufficient amount of supplies for personal hygiene. Soap, paper towels and toilet paper are provided by the Licensee. Grab bars are secured in toilet and shower areas. Showers have non-slip bottoms or mats. Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for current Medical Assessments with TB results, Current Appraisal Needs and Service plans, and signed Admission Agreements. Planned activities are offered to residents in care. Resident files reviewed were in compliance. Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations, Health screening with TB results, current First Aid/CPR, and Administrator Certificate. Three out of five staff records reviewed indicate that there is insufficient documentation showing that staff met the minimum hours of required annual training. Deficiency cited. Medications are in a centrally stored and locked room next to the kitchen, including over-the-counter medicines. Medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the residents’ doctor. Proper medication dispensing instructions are followed. The first aid kit has all proper items and is current. Exit interview conducted, deficiencies cited, and the report and appeal rights given.