Routine inspection·March 7, 2024

Licensing Program Analysts (LPAs) Alviso and Florio conducted a Required- 1 Year visit, on 3/7/24, at approximately 8:30am, and met with Health Services Director, Janice Foster. The Administrator Janna O'Sullivan, will be arriving to the facility to meet with the LPAs, per Health Services Director. Facility has an approved dementia plan of operation. There is an approved hospice waiver for ten (10) residents. Facility has an infection control plan as required. The facility has a required emergency & disaster plan. Fire clearance is approved for one hundred fourteen (114) non-ambulatory, of which six (6) may be bedridden. LPAs started reviewing staff files, including annual training. LPAs toured the facility with the Administrator and Health Services Director. The exits were observed to be clear throughout the facility during the tour. Medications were locked and inaccessible to residents, and all others that are not trained to handle medications. Medications were observed to be stored appropriately in both the memory care unit, and assisted living area. Cleaners/toxins were observed to be locked up and inaccessible to residents in care. LPAs observed the housekeeping carts to be locked during the tour, which makes any cleaners/toxins inaccessible to residents in care. The facility had sufficient lighting in hallways, restrooms, and common areas throughout the facility. The food supply was sufficient. LPAs observed emergency disaster supplies, and 72 hour shelter in place supplies during the tour. LPAs observed random resident room bathrooms, all had grab bars, and non-skid flooring in showers for resident use. This annual will be completed at a later date.