Routine inspection (multi-day)·May 16, 2025

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct an unannounced Case Management - Annual Continuation to continue the inspection that began on 05/09/2025. LPA Mosley entered the facility at 10:10 a.m. Upon arrival, LPA Mosley was greeted by staff and Administrator. LPA met with Administrator, Tammy Frame and explained the reason for the visit. The LPA and Administrator briefly toured the physical plant areas inside and outside at 10:20 a.m. to ensure there were no health and safety hazards and facility is in compliance with Title 22 Regulations. Entrance interview conducted. Infection Control / Emergency disaster planning: During today’s visit LPA Mosley reviewed the facility’s infection control practices and emergency disaster plan. The facilities policies and procedures as they pertain to infection control and emergency preparedness are satisfactory. RECORDS : Records review began at 10:51 a.m., five (5) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, current needs and services plan, and hospice records. All records in order. At 12:08 p.m. three (3) 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. Report Continued on LIC 809-C (PAGE 2) Report Continued from LIC 809... MEDICATIONS: Medications review began at approximately 1:26 p.m. Medications are centrally stored and locked in a kitchen cabinet. Medications requiring refrigeration are securely stored in a locked box inside the refrigerator, which is kept in the garage that remains locked at all times. Medications for five (5) residents were reviewed. Medications are labeled and checked for expiration dates. All medications were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed. DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster, LIC 9020A Resident roster, and current Liability Insurance. No deficiencies cited at this time. Exit interview conducted. A copy of the report was reviewed and issued.