Routine inspection·September 12, 2023

On 9/12/23 at 10:40 am, Licensing Program Analysts (LPAs) Darlene Chavez and Kelly Dulek made an unannounced Annual/Required visit to the facility listed above. LPA met with Brad Stewart, Executive Director. Hannah Myers, Administrator, was on-site during the visit. A tour of the physical plant was assessed, and the following was noted: LPA Dulek observed the license posted, Complaint Poster, Bill of Rights and Right to Residential Council, non-discrimination statement, and resident rights in common areas throughout the facility. 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 smoke detectors and carbon monoxide detectors are hard-wired. Fire extinguishers located throughout the facility were fully charged, however, last inspection was completed on 6/15/22. Licensee will have extinguishers inspected and send photos to LPA by 9/19/23. There are no issues with Fire Clearance. Living space 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 area 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. Resident rooms are adequately dressed with sheets, pillowcase, mattress pad, 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. Storage has sufficient amounts of personal hygiene product which is provided by the licensee. Continued on 809-C. Bathrooms were checked for cleanliness and proper operation. Hot water temperatures measured were within regulation. A sampling of medications show medications for one resident were stored in their room, and the physician report (LIC 602) indicates they cannot store nor administer their own medications. Deficiency cited. 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. All five residents need dentist information added to the Identification and Emergency Information Sheets. Technical violation issued. Planned activities are offered to residents in care. Staff records . LPA conducted a file review of 5 staff for criminal record clearances/associations, current First Aid, and training. One out of five staff files reviewed indicate staff do not have documentation showing negative TB tests. Deficiency cited. One out of five staff files reviewed indicate staff was not associated with the facility. Deficiency cited, civil penalty issued. The first aid certification for all five staff is complete. Five out of five staff records reviewed indicate annual training was not completed. Deficiency cited. Quarterly emergency disaster drills have been completed. Liability Insurance : LPA observed an email provided by Executive Director indicating the facility has liability insurance, however, it was not sent by the insurance company. Dates of coverage are 11/1/22 through 11/1/23 with required coverage amounts. Technical violation issued. Licensee will provide proof of liability insurance to LPA by 9/13/23. Exit interview conducted, deficiencies cited, civil penalty given, technical violations issued, and the report and appeal rights given.