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 Six (6) residents. The facility is approved for 6 non-ambulatory residents, with an age range of residents sixty (60) years of age and older. The facility has an approved Hospice Waiver for Two (2) residents. The physical plant of the facility consists of five (5) bedrooms, three (3) restrooms, with kitchen, family room, dining room, garage, two (2) Staff member rooms, and backyard outdoor area. The backyard area has a gazebo that provided shade for residents with outdoor furniture. The restrooms are communal, with three of the restrooms attached to two resident rooms each. The facility contains an outside area for residents to utilize for outdoor activities/outdoor visitations and an outdoor patio area with furniture and shade.

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 in a locked drawer 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). 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. Continued on 809-C

COMMON AREAS: The indoor areas of the facility consist of 5 bedrooms, 3 restrooms with kitchen, family room, dining room and 2 Staff rooms. At the time of the visit, the common areas of the facility were observed to be appropriately furnished, with all furniture in good condition. There is a fireplace in the family room of the facility, which is inaccessible to residents. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector(s) were operational at the time of the visit. The facility has a fire extinguisher that was fully charged and serviced annually. This facility contains a locked centrally stored medication containment area, extra storage areas for additional perishable food, closets/rooms in the hallways of the facility containing extra linen/bedsheets/pillows, and storage areas for resident personal hygiene equipment constituting the interior areas of the facility. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity supplies and equipment, including activity materials for the residents such as television, puzzles, games, etc. All window screens were in good repair. There is appropriate lighting in the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all inclines are well-lit with no stairwells/stairs for resident use. The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature. Hallways, bedroom doors, and walls are in good repair.

OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility is well maintained and consists of cement walkways and grass areas. 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 exterior of the facility has a closed perimeter which consists of a wall around the entire facility with latched gates. Inside of the perimeter is the 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. The designated laundry area is a Staff only locked room/garage of the facility, and there is another locked storage area where cleaning products are stored, which are kept locked and inaccessible to residents. Staff members are the only individuals allowed to do laundry and the entire room is kept locked at all times. Continued on 809-C

BEDROOMS: The facility consists of five (5) bedrooms, with the smaller of the two living rooms being converted into an additional bedroom for Staff. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The bedrooms have storage areas for clean linens, towels, pillows, etc. Each resident’s bedroom has a single bed or beds, nightstand, and lights/nightstand lamps to provide sufficient lighting. 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 the beds, furniture, and any resident assistive device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. All resident bedrooms in the facility contain sliding doors to the exterior of the facility, monitored by the auditory system in place by the facility that alerts Staff when a door exiting the facility has been opened.

RESTROOMS: There are three (3) resident restrooms, being double entry bathrooms that are attached to two (2) resident rooms each. The 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 at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit. Nightlights are installed in the hallways outside of the resident restrooms. All resident restrooms consist of a sink and toilet, while the resident shower/bathing areas consist of a shower and/or bathing area with grab bars and non-skid surfaces.

RECORDS: The facility keeps confidential storage of both resident and Staff member records on-site at the facility. 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 exit plans with necessary telephone numbers. The facility keeps posted copies of facility documentation such as the RCFE License Certificate, LIC 500 Personnel Report, Documentation of Facility Waivers, Plan of Operation, Emergency Disaster Plan for Residential Care Facilities for the Elderly (RCFE), 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.

LPA noted that no violations, technical assistance, or 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.