Routine inspection·November 15, 2023

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:33PM. LPA initially met with facility staff. Facility Designee was contacted via telephone and arrived at the facility at 12:53PM. Entrance interview conducted. Beginning at 01:08PM, the LPA, along with Facility Designee and facility staff 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. The following was observed: Hardwired combination smoke and carbon monoxide detectors were tested at 02:47PM and were functional at the time of the visit. Fire extinguishers were observed to be fully charged and last serviced on 09/15/2023. BEDROOMS: There are 5 (five) total bedrooms, of which 2 (two) are designated as private resident rooms, 2 (two) for shared resident use, and 1 (one) staff room. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: The LPA observed 2 (two) restrooms in the facility. 1 (one) is for shared use and 1 (one) is designated as a private restroom. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in the shared resident restroom and measured within the required range. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened. KITCHEN : Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of Report Continued on LIC 809-C perishable and non-perishable food. Knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Emergency food and water was observed. Adjacent to the kitchen is a locked garage. Garage was observed and contained the laundry area, extra food, cleaning supplies and storage. OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits and passageways were observed to be clear of hazards. RECORD REVIEW: Beginning at 01:25PM, staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 4 (four) resident records reviewed were complete and contained all required documents. 5 (five) staff files reviewed were complete and contained all required documents. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, as required. Emergency drills are conducted quarterly, with the last drill documented on 09/15/2023. MEDICATION REVIEW: Medications for 2 (two) residents were observed. Both 2 (two) of 2 (two) residents' medications were observed to be maintained and administered in compliance with regulation. INTERVIEWS: Throughout the visit, LPA interviewed 1 (one) staff and 1 (one) resident. During today's visit, LPA gathered the following items: LIC 500 A copy of the facility's liability insurance No deficiencies cited. Exit interview conducted. A copy of the report was provided.