Routine inspection·February 15, 2024

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:45AM. LPA initially met with facility staff. Licensee/Administrator was contacted via telephone and arrived at 10:32AM. Entrance interview conducted. Beginning at 10:43AM, t he LPA, along with Licensee/Administrator 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 smoke detectors and fire doors were tested at 01:58PM, separate carbon monoxide detectors were tested at 02:00PM. All were functional at the time of the visit. Fire extinguishers were observed to be fully charged and last serviced on 11/16/2023. KITCHEN : Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Adjacent to the kitchen is the locked facility garage, which contains a laundry area, locked chemical storage, extra food supply, emergency food and water as well as storage. BEDROOMS: There are 4 (four) total bedrooms, of which 2 (two) are designated for private resident use and 2 (two) are designated for shared use. Previously, the facility contained a staff bedroom, however Licensee requested conversion of the staff room to a resident room and fire clearance was approved on 07/22/2023. During today's visit, the LPA observed all resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report Continued on LIC 809-C RESTROOMS: The LPA observed 2 (two) restrooms in the facility; 1 (one) is for shared use and 1 (one) is designated for private resident use. 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 private 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. An adequately screened fireplace was observed in the living room. OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits and passageways were observed to be free of hazards. RECORD REVIEW: 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. 3 (three) resident records were reviewed; all 3 (three) 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 02/04/2024. 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. First aid kit was observed to be complete. INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) residents and 2 (two) staff. No citations issued. Exit interview conducted. A copy of the report was provided.