Routine inspection·December 5, 2022

Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 1:45 p.m. The LPA met with Administrator Cilva Toume and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN : Knives were locked inaccessible in the kitchen cabinets, and the chemicals are kept in the garage. Appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food. BEDROOMS : Bedrooms were furnished appropriately; beds were observed with clean linens and rooms had sufficient lighting. All direct exits were clear, and no obstructions were noted. RESTROOMS : Restrooms were clean and sanitary with grab bars and non-skid surfaces. At 2:10 p.m., water temperature measured at 124 F. Upon observation, the Administrator adjusted the water tank. Restrooms were fully stocked. Hand-washing signs were observed in all restrooms. COMMON SPACES : There was a hallway closet with extra linens and towels. Smoke and common monoxide detectors were operable at that time. Medications were locked and inaccessible in the kitchen cabinet. Fire extinguisher was fully charged but there was no proof of purchase or it being serviced within the past twelve (12) months. The backyard had furniture and a covered area for resident use. There was an in-ground pool but it was locked at the time of the visit. The side gate was self-latching. While touring the facility with the Administrator, the garage was observed to be unlocked during today’s visit. The washer and dryer were in the garage, along with additional supplies. As the garage was observed to be unlocked at the time of the visit, the chemicals and cleaning supplies were accessible, and over-the-counter medication was observed in the refrigerator in the garage. INFECTION CONTROL: There was a central entry point for screening and temperature checks. The LPA was appropriately screened upon entry into the facility. Staff were wearing appropriate face coverings. Infection Control signs were observed at the entrance into the facility. The facility’s cleaning protocol was sufficient. There was record of staff and resident vaccinations. The Administrator is up to date regarding testing, visitation and vaccine requirements. The Administrator communicated that they needed additional Personal Protection Equipment (PPE); however, they have a sufficient supply at this time. The facility continues to conduct surveillance testing of staff and residents on a regular basis. The facility's procedures as it pertains to infection control are adequate. Observed deficiencies noted on LIC 809D. Exit interview conducted, and a copy of this report issued. Appeal rights discussed.