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25 | On 10/27/2023 at 10:10 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Tracy Burke and explained the purpose of the visit. The facility’s fire clearance was approved for 06/28/2023.
At around 12 pm, LPA inspected the facility including but not limited to resident apartments, bathrooms, dining rooms, common living areas, kitchen, and outside areas. The room temperature and lighting were adequate for the safety and comfort of the residents. Rooms were furnished appropriately and observed to be clean and in good repair. All rooms have private bathrooms and showers which were equipped with grab bars and safety/nonskid floors/mats. There was an adequate supply of 2 day perishable and 7 day non-perishable foods. Refrigerator temperature is measured at 35 degrees Fahrenheit. Freezer temperature was measured at -10 degrees Fahrenheit. Kitchen and food preparation areas were observed to be clean and in compliance. There were no bodies of water or fire safety hazards observed. All indoor and outdoor passageways were kept free of obstruction. Facility is equipped with interconnected smoke detectors, sprinklers, and fire alarm. Memory Care Unit doors were equipped with delayed egress. Fire extinguishers throughout facility were fully charged and last inspected on 10/1/2023. Last Fire/Earthquake Emergency drill was conducted on 7/1/23. The facility's fire clearance is approved for 103 residents (all of which may be non-ambulatory and 20 bedridden). The facility has a written emergency disaster plan posted dated 7/1/23. Administrator is on site at least 40 hours a week to oversee the business operation. There is an adequate number of trained staff to meet residents' needs during inspection. Staff assisting with activities of daily living and medications had the necessary training. LPA observed hot water temperature measured in residents apartments measured at 110 degree Fahrenheit.
LPA reviewed 10 residents’ records and reviewed 10 staff records and 10 of 10 have current first aid training and associated to the facility. LPA reviewed 10 resident files and review resident’s stored medications, and Medication records. LPA observed centrally stored medications were locked and inaccessible to residents.
No deficiencies cited during visit. Exit interview conducted and a copy of this report provided via email.
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