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25 | Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with staff and explained the reason for the visit. LPA and staff toured the facility. The facility is licensed for 120 residents of which 58 may be non-ambulatory (first floor only) and a hospice waiver for 18. The facility is a two story building with an interior courtyard. LPA observed the See Something Say Something poster (PUB 475) posted in the main lobby of the facility. LPA toured 10 resident rooms. LPA observed all resident rooms had the required furnishings and bed linens. Each smoke/carbon monoxide detector in the resident rooms inspected, tested operational. LPA observed that all resident bathrooms inspected were clean and operational. Hot water measured from 106.4 degrees Fahrenheit to 119.0 degrees Fahrenheit. LPA observed no obstacles or hazards inside of the facility. LPA toured the courtyard. There is fountain in the courtyard which is filled with plants and has no water There is shaded seating for residents to sit outside. No obstacles or hazards observed in the courtyard. LPA observed all the fire extinguishers in the facility are fully charged. LPA and staff toured the kitchen and dining room. LPA observed the kitchen is clean and operational. The refrigerators and freezers are at the required temperatures. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed a 3 day emergency supply of food and water stored in a storage room. LPA observed the medication room is kept locked and all of the medication are kept locked in the medication carts. The first aid kit in the medication room has all the required elements. LPA observed all cleaning supplies are kept locked in a storage closet. The facility has 3 stairways. LPA observed an emergency evacuation chair in each stairway. Administrator Glen Goldsmith arrived after the LPA and staff toured the facility. The Administrator's certificate expires on June 16, 2025. The last emergency drill was conducted on January 28, 2025. LPA reviewed 10 resident files and medications. no discrepancies observed. LPA reviewed 5 staff files. All staff had the required training. No discrepancies observed. All staff present at the facility are background cleared and associated to the facility. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided. |