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 Fourteen (14) residents. The facility is approved for Thirteen (13) non-ambulatory residents, of which Three (3) may be bedridden, with an age range of residents sixty (60) years of age and older. The facility has an approved Hospice Waiver for Seven (7) residents. The physical plant of the facility consists of two connected buildings with resident bedrooms, restrooms, shower areas, a beauty salon, Staff offices, laundry room area, storage room areas, and Staff office rooms/areas. The facility contains an outside area for residents to utilize for outdoor activities/outdoor visitations and an outdoor patio area with furniture and shade. The exterior of the facility has an approved secured perimeter which consists of a metal fence around the entire facility with locked gates. The gates are locked through a combination of electronic punch numbered locks as well as traditional key locks.

KITCHEN: 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). Additional perishable food items were maintained in a storage area in the garage of the facility as well as an 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. Continued on 809-C

COMMON AREAS: 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 facility, located in the dining area/living room that is covered an 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 multiple fire extinguishers that were fully charged and serviced annually. This is a single-story facility with a main dining room/living room area, kitchen area, salon, laundry room, 12 resident bedrooms, 4 restrooms, a locked centrally stored medication containment area, extra storage areas for additional perishable food, cupboards 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 laundry area for the facility is located in a locked room area off of the interior hallway of the facility that is inaccessible to residents. There is a main entrance walkway into the facility and an administrative entrance area for visitors. The facility has electronic auditory systems on all doors that can exit the interior of the facility, with a loud noise when a door exiting the facility is opened. 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. Storage areas within the interior of the facility contain extra perishable food, hygiene products, PPE material, and cleaning products.

OUTSIDE/LAUNDRY/MISCELLANEOUS: The exterior of the facility has an approved secured perimeter which consists of a metal fence around the entire facility with locked gates. The gates are locked through a combination of electronic punch numbered locks as well as traditional key locks. Inside of the locked perimeter is the outdoor/outside activity area for residents with a patio, furniture, shade, benches, and grassy areas. 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 twelve (12) designated resident rooms in the facility with either 1 resident per bedroom or shared bedrooms with 2 residents per bedroom. The bedrooms have storage areas for clean linens, towels, pillows, etc. Each resident’s bedroom has a single bed, 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 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.

RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are four (4) resident bathrooms in the facility. All restrooms 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. The facility maintains both communal restrooms for residents in the hallways of the facility, as well as a personal restroom for residents in a shared bedroom. Continued on 809-C

MEDICATIONS: The facility maintains a locked centralized storage area for resident medications. Centrally Stored Medications are in a locked room that has a combination electronic lock on the door, which remains locked at all times, inaccessible/locked to residents. The locked room with the centrally stored medications is off of the dining room/living room area of the facility, at the end of the hallway from resident rooms and storage areas. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record, The Medication Administration Record, and the record of Controlled Medications. 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. Continued on 809-C

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.

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