According to the facility’s license, the facility has a maximum capacity of 175, age 60 and above, 30 of whom may be bedridden on the first floor only. A hospice care waiver is approved for thirty (30) residents. The facility is equipped with delayed egress and secured perimeter in the dementia unit. During today’s inspection, according to records, there were a total of 129 residents in care.

During the visits, LPA, accompanied by Building Engineer Mario Castaneda, toured the interior and exterior of the facility and inspected common areas and a sampling of resident bedrooms. LPA privately interviewed multiple staff and residents. LPA also reviewed multiple staff and resident records/files. The files which were reviewed contained the required documents.

The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained required furniture. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Confidential records and centrally stored medications were kept in locked areas.

The facility had at least two days of perishable food and seven days of non-perishable food present. The facility had cooking and dining utensils to facilitate resident meal service. The Walk-In Refrigerator’s temperature was compliant at 40 F, and the Walk-In Freezer’s temperature was complaint at 0 F. The facility’s ambient internal temperature was compliant at 68 F. [CONTINUED ON LIC 809-C]

Smoke and fire alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. Complete first aid kits were present and readily accessible. Licensee presented proof of current/active business liability insurance. Required licensing postings were observed in visible areas of the facility.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Wes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.