This is a Pre-Licensing inspection visit to a currently operating facility due to a change in ownership. 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.

KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in the kitchen are 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 trash cans 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 facility has outdoor activity spaces, and is enclosed by a fence with self-closing latches and/or gates or walls. There are 2 side gates from the facility which are delayed egress self-closing. Auditory devices are in place to monitor exits, if exiting presents a hazard to any resident. There are also 5 areas of the facility monitored by video surveillance cameras including the main front door, Delivery door, dining patio, and both delayed egress self-closing gates. Outdoor activity spaces and the dining patio for residents are equipped with furniture for resident use. All outdoor areas with stairways, inclines, ramps, or open porches have accessibility ramps for residents, are well-lit, and have hand railings/grab bars. There were no bodies of water noted. This is a facility with over 16 residents, therefore there is a designated laundry room where cleaning products are stored, which is kept locked. The laundry room is accessible through a staff only section of the facility down the stairs from the common areas of the facility. There was emergency food and water in a storage room/area 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.

Continued on 809-C

RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are non-private restrooms in the common areas of the facility as well as private restrooms in the resident’s bedrooms. 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. There is at least 1 toilet and sink for each 6 residents, and at least 1 bathtub/shower for each 10 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 LIC 501 personnel records, LIC 503 health assessments with Tuberculosis (TB) test results, Personnel Action Notice, Job Description with date of employment, LIC 9052 Employee Rights, LIC 508 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 LIC 603 Pre-Admission/Placement appraisals, LIC 602 Physicians Reports, Consent Forms, Personal Rights for Residents, LIC 601 Emergency Information, LIC605A Release of Medical Information, PRN Authorization, Needs and Services Plan (ANS), Resident Assessments, Mini-Mental State Exam (MMSE) for residents with dementia, Self-management of medications if applicable, Medication Orders, Medication Logs, Advance Directives, Conservatorship Documentation, and Physician Orders for Life-Sustaining Treatment (POLST). All resident records reviewed by the LPA had the appropriate documentation with no missing or incomplete information. 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, with a current Infection Control Plan in place signed by the administrator.

FACILITY DOCUMENTATION: There are required postings throughout the facility, including emergency exiting plans with necessary telephone numbers. The facility keeps hard copies of the LIC 200 Application for an RCFE, LIC 215 Applicant Information LIC 308, LIC 400 Affidavit Regarding Client/Resident Cash Resources, LIC 401 Monthly Operating Statement, LIC 402 Surety Bond, LIC 401(a) Supplemental Financial Information, LIC 403 Balance Sheet, LIC 404 Financial Information Release and Verification, LIC 500 Personnel Report, LIC 501 Personnel Record, LIC 503 Health Screening Report, LIC 610E Emergency Disaster Plan for Residential Care Facilities For the Elderly, LIC 9282 Residential Infection Control Plan, LIC 999 Facility Sketch, and the Rental Agreement signed and dated 04/01/2023 with a copy of Cashier’s Check. The facility additionally has a 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, Sample Food Menu, Theft & Loss Policy, Neighborhood Complaint Policy, Hazard Assessment, and Job Description for the Administrator. The facility has on file a Dementia Care Plan document as well as Hospice Care Waiver.

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