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 (RCFE) with 4 bedrooms, (2 individual resident bedrooms & 2 shared resident bedrooms). This facility has an age range of 60 years and older; approved for a fire clearance capacity of 6 non-ambulatory residents, 2 of which may be bedridden. The facility has a hospice waiver approved for 6 residents.

KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in locked drawers 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 storage area in the garage of the facility as well as in 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. 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 concrete steps and an open porch with tables and chairs. The front of the facility is contained by a stone/concrete wall with a gate that remains unlocked. 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 is a swimming pool in the backyard of the facility that is completely enclosed by a metal fence approximately 6 feet high with a gate closed at all times. The designated laundry area of the garage is where cleaning products are stored, which are kept locked and inaccessible to residents. The laundry area is accessible through the common area of the facility as an addendum to the kitchen area. 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. The vehicles used to transport residents are in safe operating condition with appropriate insurance information. LPA noted that outside in the back yard is completely enclosed by two gates on either side of the facility and has appropriate furniture for residents as well as shade. LPA did not observe any noticeable outdoor hazards. Continued on 809-C

RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are multiple resident bathrooms in the facility. All restrooms inspected had assistive 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 6 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. Resident records were reviewed for Pre-Admission/Placement appraisals, Physicians Reports, Consent Forms, Personal Rights for Residents, Emergency Information, Release of Medical Information, Needs and Services Plan (ANS), Resident Assessments, Self-management of medications if applicable, Medication Orders, and Medication Logs. 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.

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 exiting plans with necessary telephone numbers. The facility has copies of the Application for an RCFE, Applicant Information, Designation of Facility Responsibility, Affidavit Regarding Client/Resident Cash Resources, Surety Bond, Personnel Report, Personnel Record, Health Screening Report, Emergency Disaster Plan for Adult Residential Facilities, 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.