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25 | Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 03/29/2023 at 12:20pm. LPA met with facility Assistant Administrator Anne Roxas (Admin).
LPA toured the facility, including living room, activity room, dining room, kitchen, laundry room, 10 bedrooms, 3 bathrooms, medicine room, and patio. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.
Facility Mitigation plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Facility water temperature measured at 119.7*F. Bathrooms observed to be equipped with grab bars and nonskid mats. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be inspected in March 2023. Smoke/carbon monoxide detectors tested and observed to be operational.
LPA interviewed 10 facility residents and 5 facility staff. 10 out of 10 residents interviewed expressed satisfaction with facility care. 5 out 5 staff interviewed demonstrated understanding of all elements of position duties. 10 out All staff members present at the facility were observed to be fingerprint cleared on Guardian. LPA reviewed the resident medications, resident records, and staff records. No medication was noted to be missing during review. All staff and resident files observed to be complete. Facility disaster plan and plan of operation were observed to be complete and reviewed within a year's time.
No deficiencies cited during today's visit. This report was reviewed with Assistant Administrator Anne Roxas and a copy of the signed report was provided digitally due to printer error. |