The LPA and the 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.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was fully charged and was last serviced on 01/15/2024. The LPA observed some of the required postings throughout the common space. The CCL poster “If you see something, Say Something” poster was not available at the facility. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and were not functional at the time of visit.

KITCHEN: At 11:35 a.m. the LPA and administrator observed two kitchen knives on the kitchen counter and in an unlocked kitchen drawer to be accessible to residents in care. All other knives are stored inaccessible in a kitchen drawer. Kitchen appliances were in operable condition. Kitchen cleaning supplies were observed under the kitchen sink in an unlocked cabinet, and accessible to residents in care. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at 112.8 degrees Fahrenheit.

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BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four designated client rooms. All beds were observed to have full bedrails, although bedrails were not observed to be in the upright position. In bedroom #2, was observed to have a small locker type cabinet with six (6) compartments. The compartments have locks. The Administrator stated that the small locker is used by staff to put away their belongings. Locker will be removed.

BATHROOMS: Two bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces in one bathroom. The private bathroom need to have safety grab bars installed. The bathrooms were sufficiently stocked with soap and paper towels. Trash cans did not have a tight closing lid. The hot water temperature measured in the hallway restroom at 119.9 degrees Fahrenheit.

LAUNDRY ROOM: A laundry area was observed with unlocked folding doors. A bottle of detergent was observed on the washer. An unlocked cabinet over the washer and dryer which has personal item supplies and scissors, was observed to be unlocked, accessible to residents in care.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted.

RECORDS: Records review began at 1:35 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. Three out of four residents’ files were missing some or all of the following required forms: LIC 601, LIC 613, LIC 621. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Three out of four residents’ files were missing some or all of the following required forms: 20-hour required annual training, Criminal Statements, CPR/First Aid, Personnel Record.

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MEDICATIONS: Medications review began at 3:45 p.m.; medications are centrally stored and locked in a cabinet in the common area; medications are labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record form (LIC622). Errors observed during the medication review, as four out four residents’ LIC 622 forms ere filled out incorrectly, and at least one medication: Quetiapine 25mg/30 was found to have six(6) more pills than the correct amount.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA reviewed the following documents:

Exit interview conducted. A copy of the report and Appeal Rights was issued.