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 dining room area of the facility, which is inaccessible to clients. There are also activities available for clients such as board games, puzzles, and reading materials located in the dining room area. Continued on 809-C

OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility consists of cement walkways and grass areas along with a parking area in front of the main entrance to the facility. The facility outdoor areas are maintained with no observable hazards to clients 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 backyard has a covered outdoor area equipped with furniture for client use. The side gate was audio egress self-closing and latched. The garage is locked. Residents have a designated smoking section located in the backyard with an appropriate waste disposal for cigarettes. There is an outdoor/outside activity area for clients 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 located in a segment of the facility off of the main hallway next to the living room and client bedrooms. All toxic and/or cleaning products that could constitute a danger to any client(s) are stored and kept locked and inaccessible to clients. Clients are allowed to do laundry, but any hazardous/toxic laundry material is kept locked at all times. There was emergency food and water in a storage area in the back of the facility and in the extra perishable food storage area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to clients are kept in areas inaccessible to clients. There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport clients are in safe operating condition with appropriate insurance information. LPA did not observe any noticeable outdoor hazards in areas accessible to clients. There is a main entrance walkway into the facility and an administrative entrance area for visitors. Continued on 809-C

RESTROOMS: There are Three (3) client restrooms in the facility. Facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms/showers inspected had assistive equipment for clients 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 client restrooms. All client restrooms consist of a sink and toilet, while the client 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 client and Staff member records on-site at the facility. Staff member records were reviewed for, but not limited to Health Screening Report/Tuberculosis (TB) Clearance for facility personnel, Personnel Record (employment application), verification of age over 18 years old, education, and experience, approved Certification for the Administrator, verification of first aid training, Criminal Record Statement, Criminal Record Clearance/Exemption, Verification of Staff training, Employee Rights, and Abuse Reporting Requirements. All staff members’ personnel records reviewed by LPA had the appropriate documentation. One Staff member was not associated with the facility, but was a re-hire had all the correct records completed and the association was completed during the visit by the LPA. The administrator has a pending Administrator Certificate renewal. Client records were reviewed for, but not limited to Pre-Admission/Placement appraisals, Client Appraisals, Appraisal Needs and Services Plan (ANS), Physicians’ Reports, Identification and Emergency Information, Current Admission Agreement with signatures, Personal Rights for Clients, Record of Clients safeguarded cash resources, Record of Client personal property/valuables, Responsible Person or Conservator of Client, Self-management of medications if applicable, Medication Orders, and Medication Logs. All client records reviewed by the LPA had appropriate documentation with no missing/incomplete information. Contd. 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 Adult Residential Facilities (ARF), 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, clients, 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.