The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE), with an approved fire clearance capacity of Five (5) residents. The facility is currently occupied by Two (2) residents.

KITCHEN: The facility maintains a kitchen room/area within the interior of the facility. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored inaccessible to residents. Kitchen appliances were in operable condition and in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last over a week (7 days). The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation between 105-120 degrees Fahrenheit. Items that could constitute a danger to clients are kept inaccessible to clients in the kitchen area. The kitchen was sanitary, with covered trashcans and operating ventilation systems. However, LPA observed that kitchen cabinets, counters and tables were not clean. Dust and several flies were observed. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerator were both the appropriate temperate Fahrenheit for the storage of food and prevention of spoiling. There is enough tableware and utensils for all clients living in the facility, and enough equipment for the storage, preparation, and service of food.

COMMON AREAS: At the time of the visit, the common areas of the facility were observed to be furnished with appropriate furniture, with all furniture in fair condition. Continued on 809-C

OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility consists of cement walkways and grass areas along with a parking area in front of the main entrance to the facility. The facility outdoor areas are maintained with no observable hazards to residents in care. The backyard/patio room is conducive for outdoor visitation. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. The backyard of the facility has an outdoor/outside activity area for residents with a patio in the backyard, furniture, and shade. There are no bodies of water noted on the facility property. Laundry cleaning products are stored locked and inaccessible to residents. Any hazardous/toxic laundry material is kept locked at all times. There was emergency food and water in a storage area in the back of the facility and in the extra perishable food storage area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents. There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport residents are in safe operating condition with appropriate insurance information. LPA did not observe any noticeable outdoor hazards in areas accessible to residents. The facility Licensee/Administrator maintains two dogs that were very well trained as observed by the LPA. There is a main entrance walkway into the facility and an administrative entrance area for visitors.

BEDROOMS: The facility consists of two (2) bedrooms, with all bedrooms being for individual residents. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Continued on 809-C

RESTROOMS: There are Two (2) resident restrooms in the facility. Facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms/showers inspected had assistive equipment for residents including grab bars and/or non-skid surfaces. The restrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms within the appropriate temperature regulations. Nightlights are installed in the hallways outside of the resident restrooms. The restrooms both had sufficient required postings. One of the restrooms had damage to the toilet as well as the wall behind the toilet, but this was not observed by LPA to constitute a danger to resident(s).

RECORDS: The facility keeps confidential storage of resident file(s) at the facility, and Staff member records on-site at the facility as well as the facility next door operated by the same Licensee/Administrator. Staff member records were reviewed for, but not limited to Health Screening Report/Tuberculosis (TB) Clearance for facility personnel, Personnel Record (employment application), verification of age over 18 years old, education, and experience, approved Certification for the Administrator, verification of first aid training, Criminal Record Statement, Criminal Record Clearance/Exemption, Verification of Staff training, Employee Rights, and Abuse Reporting Requirements. Staff personnel records reviewed by LPA had the appropriate documentation. The administrator of the facility has an active Residential Care Facility for the Elderly (RCFE) Administrator Certificate that will expire on 11/02/2024. Resident records were reviewed for, but not limited to Pre-Admission/Placement appraisals, Resident Appraisals, Appraisal Needs and Services Plan (ANS), Physicians’ Reports, Identification and Emergency Information, Current Admission Agreement with signatures, Personal Rights for Residents, Record of Residents safeguarded cash resources, Record of Resident personal property/valuables, Responsible Person or Conservator of Resident, Self-management of medications if applicable, Medication Orders, and Medication Logs. All resident records reviewed by the LPA had the appropriate documentation with no missing or incomplete information.

MEDICATIONS: Facility maintains a locked centralized storage area for medications. Contd. on 809-C

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. 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 facility’s policies and procedures as it pertains to infection control are adequate.

FACILITY DOCUMENTATION: There are required postings throughout the facility, including emergency exit plans with necessary telephone numbers. The facility keeps posted copies of facility documentation such as the facility Personnel Report, Plan of Operation, Emergency Disaster Plan, Facility Infection Control Plan/Mitigation Plan, Certificate of Liability Insurance, Valid Administrator Certificate, and a Facility Sketch. Provider Information Notices are available and able to be presented to Staff, residents, visitors, and accessible to LPA upon request during the inspection process. All vehicles used to transport residents are maintained in safe operating condition.

LPA noted that there were several technical violations issued, but no citations were issued during this annual inspection at this time.

No deficiencies cited. Exit interview conducted. A copy of the report was issued to the facility.