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25 | At 1:45 p.m. on 04/16/24, Licensing Program Analysts (LPAs) Nicholas Reed and Leizl de la Cerra conducted an unannounced annual inspection. LPAs met with staff and disclosed the reason for the visit.
LPAs and staff toured the facility inside and out at 1:55 p.m.
The facility was last visited on 01/11/2023 for a complaint visit. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents, of which 1 may be bedridden in Bedroom #2. The facility serves residents with dementia. Approved hospice waivers for three (03).
LPAs observed a maintained front yard with surveillance cameras at the front. At the main entrance, LPAs observed postings for emergency contacts, confidential complaint contacts, Ombudsman contacts, personal rights, theft and loss policy, administrator certificate, facility sketch with evacuation routes, visitation policy, non-discrimination notice, activity schedule, and COVID postings. LPAs observed a screening station with digital thermometer, visitor log, sanitizer, masks, and additional PPE.
Walls, floors, windows, screens, and blinds were clean and in good repair. At 2:00 p.m. LPAs measured the room temperature to be 76 degrees Fahrenheit. Four (04) residents were observed watching television in the living room together. Reading materials, activity books, and games were available near the dining room table.
The facility has four (04) bedrooms. One (01) bedroom is designated as a staff room. The staff room was free of hazards. Resident bedrooms were all shared bedrooms. All bedrooms contained a chair, lamp, nightstand, storage, fall prevention mats, and a bed with adequate bedding. All furnishings were clean and in good condition. Bedroom #3 contained a bed with full bed rails. At 3:30 p.m. LPAs checked and confirmed that a physician’s order was present for the full bed rails.
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