Physical Plant/Environment Safety: The facility is a single storey building located in a residential neighborhood consisting of 98 rooms, some of which are being used as model rooms, administration offices and storage rooms. There is one (1) large activity room/living room, across the activity room is a separate area for library, bingo activity area, pool table, computer room and a room designated for arts and crafts. It has a large dining room, laundry room, nurse's station, medication room and a basement parking. It is licensed to care for 120 non ambulatory elderly residents with a hospice waiver for ten (10). Current census is (81) elderly residents. The facility has Dementia residents. The main entrance/lobby area is used as the central entry point for everyone. A check-in station is set up at the front desk and Covid-19 symptom screening is initiated at entry, where LPA was screened. COVID-19 Infection Control screening protocols and supplies included a thermometer, PPE supplies, screening logs, and sign-in sheet were observed in the main lobby. COVID-19 signage was posted around the building. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has twenty six (26) fully charged fire extinguishers which were last inspected on 02/24/2023. Assistant Administrator stated that the local fire department conducted an annual inspection of the facility in February 2023. The facility has a fire suppression system which did not run properly during that time, which required a 2nd inspection on 8/14/2023. During the last fire marshal's visit, the fire suppression system worked and ran smoothly. Facility is currently awaiting for their fire clearance. Cleaning supplies and toxic substances are inaccessible to residents. Hot water temperature readings measured within the required 105-120 degrees Fahrenheit. The following random resident rooms were inspected and the water readings are as follows: Room #1 (113.9 deg F), Room #7 (112.4 deg F), Room #18 (112.7 deg F), Room #33 (108.5 deg F), Room #47 (107.4 deg F), Room #52 (116.2 deg F), Room #67 (105.6 deg F), Room #69 (105.9 deg F),

***CONTINUED ON LIC 809-C***

Personnel Records-Training: Administrator certificate expired on 8/11/2023, however, Administrator was able to provide proof that renewal was submitted to CDSS on 5/23/2023. Administrator also completed the required courses. Five (5) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and First Aid/CPR training.

Resident Records-Incident Reports: Five (5) resident files were reviewed containing admission agreements, Physician's Report, Appraisal, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed. The Incident report binder was also reviewed.

Resident Rights-Information: Resident personal rights were posted near the lobby area. The Incident report binder was also reviewed.

Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. Information regarding Dementia is part of the training for direct care staff and is included in the Plan of Operation. An activity calendar was observed posted in the hallway. The facility has a Resident Council.

Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents.

Incident Medical and Dental: All residents have Restricted Health Care Plan and Needs and Services Plan on file. Home Health personnel serviced the residents in the facility. Residents medication are centrally stored in the medication room which is inaccessible to residents. Five (5) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a quarterly basis for all staff and residents.

Residents with Special Health Needs: Twenty eight (28) residents are receiving home health services. One (1) resident receives hospice care. Postural support physician orders are on file. Half bed rails for mobility assistance were observed in resident rooms. Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions.