Routine inspection (multi-day)·October 13, 2023

License Program Analyst (LPA) Shannan Hansen arrived at 8:15 AM to complete an unannounced annual inspection and was welcomed by staff Alondra Amezcua who contacted Licensee/Administrator Kelly Sturgeon who arrived shortly after. There is a total of 6 residents, all with a diagnostic of dementia, with 3 on hospice. LPA continued inspection with a review of six resident & five staff records as well as two resident’s medications conducted. LPA reviewed resident’s files at 8:40 AM on 10/13/2023 and learned that 6 of 6 residents have an updated re-appraisals/needs & care plans and updated physician’s assessments (LIC 602A). Medications were centrally stored in locked cabinet in the facility office area between kitchen and dining room at 10:00 AM on 10/13/2023. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 10/13/2023 at 10:15 AM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. LPA reviewed a sample of staff records at 9:30 AM on 10/13/2023 and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements for 2022/2023 are on file. LPA was presented with proof of CPR & 1 st Aid certification for staff that files were reviewed although 1 staff only had CPR/AED although is signed up for First Aid today (see LIC 9102 Advisory Notes). LPA reviewed health records for staff and observed 1 staff (S1) not having proof of TB in file (see LIC 9102 Advisory Notes) Administrator sending. Kelly Sturgeon Administrator Certificate # 6023921740 expires on 1/5/2025. Continue LIC 809-C No deficiencies cited during today's inspection. LPA Hansen is requesting Licensee to update the following documents by 10/31/2023: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan – if changes LIC 9020 Register of Facility Client’s/Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurance