The LPA 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. This is an Adult Residential Facility approved for 5 ambulatory residents.

KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in the kitchen are inaccessible to residents. This consists of a locked drawer, demonstrated to the LPA, which was observed by the LPA. Kitchen appliances were in operable condition and looked clean/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. Additional perishable food items were maintained on a shelf and/or an extra freezer. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation. The kitchen was clean and sanitary, with covered trashcans and operating ventilation systems. 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 in the appropriate temperate Fahrenheit. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food.

Continued on 809-C

BACKYARD/LAUNDRY/GARAGE: The backyard of the facility is completely enclosed by a fence with self-closing latches and gates. There are side gates from the facility which are delayed egress self-closing. The backyard of the facility is equipped with furniture for resident use including shaded tables and chairs. There were no bodies of water noted. There is an additional room in the facility, a sunroom for resident use including furniture in good condition and an area for staff member office. There is a designated laundry room where cleaning products are stored, which is kept locked. The laundry room is accessible through the garage area of the facility. There was emergency food and water in a storage room/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.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are approximately 4 bedrooms for the residents. The bedrooms for residents have 1 to 2 residents per room. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and for residents to move freely unobstructed. Each room has at the least a chair, nightstand, chest of drawers, and sufficient lighting.

Continued on 809-C

RECORDS: The facility keeps confidential storage of personnel records and resident records off-site at a central office for all the facilities associated with Momentum Work Inc. LPA spoke with the Administrator/Program Manager who coordinated the viewing of records. Personnel records reviews were reviewed for, but not limited to Personnel records, Health assessments with Tuberculosis (TB) test results, Personnel Action Notice, Job Description with date of employment, Employee Rights, Criminal record Statements, Criminal record clearances, First aid/CPR certification that is not expired, and the appropriate training documentation. All staff member personnel records had the appropriate documentation with no expiration of any training. Resident records were reviewed for Pre-Admission/Placement appraisals, Admission Agreements, Physicians Reports, Consent Forms, Personal Rights for Residents, Emergency Information, Release of Medical Information, Needs and Services Plan (ANS)/Individual Program Plan (IPP), Resident Assessments, 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: The facility maintains a locked centralized storage area for resident medications. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. The centralized storage area consists of a locked cabinet in the staff office area of the sunroom in the facility, with each resident having their own locked section of the cabinet. The staff members demonstrated that the medications are locked and opened the area with a key for the LPA. The LPA audited the medications of the residents in care at the facility and found no inconsistencies or irregularities regarding medication.

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. Continued on 809-C

FACILITY DOCUMENTATION: There are required postings throughout the facility, including emergency exiting plans with necessary telephone numbers. The facility keeps hard copies on the wall in the common areas of LIC 500 Personnel Report, LIC 501 Personnel Record, LIC 610D Emergency Disaster Plan for Adult Residential Facilities, LIC 9282 Residential Infection Control Plan, and LIC 999 Facility Sketch. Provider Information Notices are easily accessible and presented to LPA upon request during inspection process.

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