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 an approved fire clearance for six (6) residents. The facility was observed by the LPA to be clean, safe, sanitary and in good repair for the safety and well-being of residents, employees, and visitors. The facility has provisioned to each resident of furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. There are currently six (6) residents in care at the facility, with two (2) residents currently receiving Hospice home health care services.

KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored 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 as observed by LPA. Additional perishable food items were maintained in storage areas in the facility. The hot water temperature was measured in the kitchen at an appropriate temperature as per Community Care Licensing (CCL) regulations. 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. 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 and grass areas with a completely enclosed metal fence/gate. The facility is contained by a metal fence 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, are well-lit, and have hand railings/grab bars. There were no bodies of water noted. However there is a fountain in the backyard area, but with no water. There is a designated laundry room where cleaning products are stored, which is kept locked. The laundry room is accessible through the common area of the facility as an addendum to the kitchen area. There was emergency food and water in a storage room/area which was observed to be in good condition. The storage area is a locked shed in the backyard of the facility. There is also a detached caregiver building in the backyard of the facility. 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.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are six (6) designated resident rooms in the facility. Each resident bedroom has a single bed, nightstands, and lights and nightstand lamps to provide sufficient lighting. Continued on 809-C

RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are six (6) private resident bathrooms in the interior of resident bedrooms. There is also one (1) shared bathroom in the common area of the facility. All restrooms inspected had assisting equipment for residents 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 CCL regulations. There is at least 1 toilet and sink for each 6 residents, and at least 1 bathtub/shower for each 6 residents. Night-lights are installed in the hallways outside of the common area restrooms. All toilets and hand washing areas are maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences are provided by the ADP to accommodate any physically handicapped residents who need such items.

RECORDS: The facility keeps confidential storage of personnel records and resident records on-site at the facility. The facility administrator meets the qualifications as specified in Title 22 regulations. Additionally, the facility administrator receives and documents continuing education each year. 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 documentation. Resident records were reviewed for Pre-Admission/Placement appraisals, Admission Agreements, Physicians Reports, Consent Forms, Personal Rights for Residents, Emergency Information, Release of Medical Information, Needs and Services Plan (ANS)/Individual Program Plan (IPP), Resident Assessments, Self-management of medications if applicable, Medication Orders, and Medication Logs. The facility complies with Community Care Licensing (CCL) standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Resident records including Admission agreements and Needs and Services plan are maintained for each Resident and/or their authorized representative.

MEDICATIONS: The facility maintains a locked centralized storage area for medications. Contd. 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 postings throughout the facility, including emergency exit plans with necessary telephone numbers. The facility maintains documentation on site such as the Fire Department Clearance, Personnel Report, Plan of Operation, Emergency Disaster Plan, Facility Infection Control Plan/Mitigation Plan, Evacuation Procedures, Personal Rights of Residents, and a Facility Sketch. Provider Information Notices are available and able to be presented to Staff, residents, visitors, and accessible to LPA. Facility documentation is prominently posted in areas accessible to residents and their visitors. The facility has on file a Dementia Care Waiver and Hospice Care Waiver.

This facility maintains a camera video surveillance system monitoring the outside areas of the facility as well as one camera located in the common area kitchen/living room of the facility.

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