Routine inspection·November 1, 2023

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 Fely Pudol. Licensee was contacted via telephone and arrived at the facility at 10:28AM. Entrance interview conducted. Beginning at 10:40AM, the LPA, along with Licensee 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 02:32PM and were functional at the time of the visit. Fire extinguishers were observed to be fully charged and purchased on 07/17/2023. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) total bedrooms for resident use and 1 (one) designated for staff use. RESTROOMS: The LPA observed 6 (six) restrooms in the facility. 5 (five) are for resident use and 1 (one) is designated for staff use. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in various resident restrooms 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. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. OUTDOOR SPACE: The backyard is shared between this facility and another related facility. The shared yard has a covered outdoor area equipped with furniture for resident use. The facility does have a fountain, but it was observed to be empty at the time of the visit. The garage was observed and contained the laundry area, as well as emergency food supply and water, and storage. 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. 5 (five) 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 monthly, with the last drill documented on 10/06/2023. INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) staff and 1 (one) resident. MEDICATION REVIEW: Medications for 3 (three) residents were observed. All 3 (three) of 3 (three) residents' prescription medications were observed to be maintained and administered in compliance with regulation. 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.