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 facility is a Residential Care for the Elderly (RCFE) that has an age range of 60 years and older for all residents in care. The facility fire clearance is approved for approved for 6 non-ambulatory residents, 2 of which may be bedridden. A hospice waiver is approved for 4 residents.

KITCHEN(S): The facility has a main kitchen for residents of the facility, and a connected dining room. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in the kitchen 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 7 days. 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. Heating devices such as stoves are inaccessible to residents, as are sharps/other items that could constitute a danger to residents. 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

OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility consists of a front courtyard with an open porch with tables and chairs. 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. The laundry room of the facility contains additional supplies/emergency supplies. The designated laundry room of the facility is where cleaning products are stored, which are kept locked and inaccessible to residents. The laundry room is accessible from the common areas of the facility and is comprised of a small hallway adjacent to the kitchen. There was emergency food and water in storage area of the garage 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. Continued on 809-C

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are 7 designated individual resident rooms in the facility, and storage areas for clean linens, towels, pillows, etc. Each resident bedroom has a single bed, night stands, and lights and night stand 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 beds, furniture, and any resident assisting device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident.

RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are 3 resident bathrooms total in the facility, with 3 shared bathrooms in the common areas of the facility and 1 bathroom being a private resident bathroom in a resident bedroom. 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 5 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.

Continued on 809-C

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. Centrally Stored Medications are in a locked cabinet in the laundry room area inaccessible to residents. LPA audited the medications for residents and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility.

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 applicable documentation including Applicant Information, Designation of Facility Responsibility, Affidavit Regarding Client/Resident Cash Resources, Surety Bond, Personnel Report, Personnel Record, Health Screening Report, Emergency Disaster Plan, 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.

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