Routine inspection (multi-day)·January 21, 2025

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced Required - 1 Year Continuation inspection and arrived at the facility at 10:30 a.m. This is a continuation from the 12/23/2024 Required - 1 Year inspection. Upon arrival, LPA was greeted by staff and Co-Administrator. Today, the LPA met with Co - Administrator Helen Rose T. Busch and explained the reason for the inspection. Co- Administrator Johnna Udden arrived during the inspection. At 10:34 a.m- 10:50 a.m the LPA briefly toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. RECORDS: Records review began at 10:53 a.m., Four (4) Personnel records including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. At 11:10 a.m. five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were in order at this time. EMERGENCY DISASTER PLAN: LPA reviewed the facility's emergency disaster plan, which was recently updated. Emergency drills are conducted quarterly, with the last completed drill documented on 11/15/2024 and the next one scheduled for February. INFECTION CONTROL PLAN: During today's visit, LPA reviewed the facility's infection control plan. The facility's policies and procedures related to infection control are adequate. (Report Continued on LIC 809C...) (Report Continued from LIC 809C...) INTERVIEWS : Two (2) staff interviews and two (2) resident interviews were conducted during the inspection. Staff interviews revealed that staff are knowledgeable in resident rights, different forms of abuse and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit. During today’s visit, the LPA obtained copies of the following: LIC 500 Personnel Report, LIC 9020 Resident Roster, and current liability insurance. No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report reviewed and provided.