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 a Residential Care Facility for the Elderly (RCFE) consisting of 8 bedrooms, (6 designated resident single rooms, 2 staff rooms) 3 restrooms, a kitchen, dining room, 2 living rooms, 1 Central Medication area (where medications are centrally stored and locked), laundry room, Staff office area, and multiple storage room areas. This facility is approved for a maximum of six (6) non-ambulatory residents, and has a hospice waiver for four (4) residents.

KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in locked drawers inaccessible to residents. 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, which would last over a week (7 days). Additional perishable food items were maintained in storage area in the garage of the facility as well as in extra refrigerator and extra freezer located in the garage of the facility. 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 residents are kept inaccessible to residents in the kitchen area. 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. The facility cooks meals for the residents on a regular basis.

COMMON AREAS: At the time of the visit, the common areas of the facility (dining room, 2 common room areas) were observed to be appropriately furnished, with all furniture in good condition. Contd. on 809-C

OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility consists of concrete steps and an open porch with tables and chairs. The front of the facility is contained by a stone/concrete wall with a gate that remains unlocked. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. Outdoor activity spaces are completely enclosed by a fence and gates or walls. Outdoor activity spaces in the backyard are equipped with furniture for resident use including a patio with an umbrella for shade. All outdoor areas with stairways, inclines, ramps, or open porches have accessibility ramps for residents, and are well-lit. There were no bodies of water noted. A laundry room is located off the backyard of the facility and contains both the laundry area, and additional supplies/emergency supplies. The designated laundry area is where cleaning products are stored, which are kept locked and inaccessible to residents. There was emergency food and water in storage areas of the facility 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 noted that outside in the back yard is completely enclosed by two gates on either side of the facility and has appropriate furniture for residents as well as shade. LPA did not observe any noticeable outdoor hazards. There are two (2) locked sheds in the backyard of the facility which contain tools, gardening supplies, and maintenance materials inspected. Contd 809-C

RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are 3 shared resident bathrooms in the facility. 1 resident bathroom is located in the master bedroom area of the facility, and the other resident bathrooms are next to the dining room and common areas of the facility. All restrooms inspected had assisting equipment for residents 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 between 105-120 degrees. As the facility only contains 6 residents at the time of inspection, there is at least 1 toilet and sink for each 3 residents, and at least 1 bathtub/shower for each 3 residents. Nightlights are installed in the hallways outside of the common area restrooms.

RECORDS: The facility keeps confidential storage of personnel records and resident records on-site at the facility. 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. All staff member personnel records had the appropriate documentation with no expiration of any training. Resident records were reviewed for Pre-Admission/Placement appraisals, Physicians Reports, Consent Forms, Personal Rights for Residents, Emergency Information, Release of Medical Information, Needs and Services Plan (ANS), 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.

Continued 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 exiting plans with necessary telephone numbers. The facility has copies of the Application for an RCFE, Applicant Information, Designation of Facility Responsibility, Affidavit Regarding Client/Resident Cash Resources, Surety Bond, Personnel Report, Personnel Record, Health Screening Report, Emergency Disaster Plan for Adult Residential Facilities, Residential Infection Control Plan, Facility Sketch, Plan of Operation, Control of Property, The Job Description for Each Staff Position, Personnel Policy, In-Service Training for Staff, Facility Program Description, Rules of Discipline/Personal Rights, Admission Agreement for Residents, Theft & Loss Policy, and Job Description for the Administrator. This facility is approved for a maximum of six (6) non-ambulatory residents, and has a hospice waiver for four (4) residents.

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