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, approved for a maximum of 6 non-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. 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 7 days. Additional perishable food items were maintained in storage outside of the kitchen/in the garage area. The hot water temperature was measured in the kitchen at an appropriate temperature, between 105-120 degrees Fahrenheit as per the regulation. Heating devices such as stoves are inaccessible to residents, as are sharps/other items that could constitute a danger to residents. The kitchen was not completely clean and sanitary, as there was miscellaneous kitchen items strewn about, but there were no items out that could be a danger to any resident in care. The kitchen had had 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.

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 a fireplace in the living room, which is covered and inaccessible to residents in care. Continued on 809-C

OUTSIDE/LAUNDRY/MISCELLANEOUS: Outdoor activity spaces are completely enclosed by a fence and/or wall. There are 2 side gates from the facility which are not delayed egress self-closing. The backyard/outdoor activity spaces are equipped with furniture for resident use with shade from the sun. All outdoor areas with any type of stairways, inclines, ramps, or open porches have accessibility ramps for residents, and are well-lit. There were no bodies of water noted. The facility has a front yard with grass, a cemented walkway around the backside of the facility, and an attached garage to the facility. The facility has a designated laundry room where cleaning products are stored, which is kept locked. The laundry room is accessible through the garage of the facility and only staff members have access. 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 facility does not currently use vehicles used to transport residents in care, but all personal vehicles previously 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 is only 1 resident in care at the facility currently, so there is only 1 resident bedroom being used at this time. There are 5 designated resident rooms in the facility, and 1 staff room in the facility. 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 any resident assisting device such as a wheelchair or a walker. Each room has at the least a chair, night stand, chest of drawers, and sufficient lighting. Continued on 809-C

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 LIC 501 personnel records, LIC 503 health assessments with Tuberculosis (TB) test results, Personnel Action Notice, Job Description with date of employment, LIC 9052 Employee Rights, LIC 508 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 LIC 603 Pre-Admission/Placement appraisals, LIC 602 Physicians Reports, Consent Forms, Personal Rights for Residents, LIC 601 Emergency Information, LIC605A Release of Medical Information, PRN Authorization, Needs and Services Plan (ANS), Resident Assessments, Self-management of medications if applicable, Medication Orders, Medication Logs, Advance Directives, Conservatorship Documentation, and Physician Orders for Life-Sustaining Treatment (POLST). 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 Centrally Stored Medications are contained in a locked file cabinet in the common area of the facility. The administrator demonstrated to the LPA the locking and unlocking of the file cabinet in preparation for an audit of the resident’s medications. There were no inconsistencies or irregularities in regard to the resident’s actual medications and the Centrally Stored Medication and Destruction Record.

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

A Technical Assistance was issued due to the facility Emergency Disaster Plan for Residential Care Facilities for the Elderly having all temporary relocation areas be within the same vicinity of the facility. The administrator agreed to change one of the temporary relocation sites to be outside the general vicinity of the facility. The LPA spoke with the administrator about the disheveled areas in the common area of the facility due to papers, bags, etc. being left out, but the administrator was in the process of cleaning these areas as the LPA arrived for the Annual site visit and had made substantial progress by the time the LPA left the facility. LPA reminded the administrator to maintain the common areas of the facility in an organized manner.

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