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 (ARF) with an approved Fire Clearance for 5 ambulatory clients.

KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in the kitchen are inaccessible to clients. 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/sanitary aside from from the kitchen table being observed to be unclean, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies are kept separately from food supplies. The freezer and refrigerator were both in the appropriate temperate Fahrenheit. 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, living room and dining room were observed to be appropriately furnished, with all furniture in good condition. There is no fireplace in the living room or dining room areas. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. 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 client use including shaded tables and chairs. There were no bodies of water noted. There is an additional room in the facility, a sunroom for client 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 clients are kept in areas inaccessible to clients. There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport clients are in safe operating condition with appropriate insurance information.

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

RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are 2 restrooms in the facility. All restrooms inspected had assisting equipment for clients including grab bars and/or non-skid surfaces. The bathrooms 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 at the appropriate degrees Fahrenheit as per the regulations. Nightlights are installed in the hallways outside of the common area restrooms. Continued on 809-C

MEDICATIONS: The facility maintains a locked centralized storage area for client 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 client 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 clients 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. 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.

Continued on 809-C

During this annual facility site inspection, no deficiencies were cited. A Technical violation was issued due to all kitchen, food preparation, and storage areas not being be kept clean; free of litter and rubbish. The LPA observed that the table used in the kitchen for client food service had bits of old food and/or spilled food as well as a sticky substance on the table. However, this was not observed by LPA to be a risk to the health and safety of residents in care. The rest of the physical plant and food service of the facility was clean, well-maintained, and within Licensing Agency regulations. There is no widespread neglect regarding maintenance of the facility, and on-going corrective action to prevent overall deterioration of the Physical Plant is being maintained by the facility.

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