Facility Evaluation Report

At approximately 9:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year Visit and met with Administrator, Paul Durancyzk. Facility is a Continuing Care Retirement Community (CCRC) and has a portion of the property licensed as a Residential Care Facility for the Elderly (RCFE). This portion of the property provides care and assistance for Older Adults in Assisted Living. Facility has an approved fire clearance and capacity for 28 Non-Ambulatory or Bedridden Residents. Facility has a Hospice Waiver for 5 individuals. Upon arrival, LPA was informed that there were currently 14 residents in care and 3 staff members on-site.

LPA conducted a walk-through of the facility and made the following observations: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has an Infection Control Plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 4 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit.

LPA reviewed staff training, resident files, and resident medications. Staff were found to have training as required. Resident files were found to be well organized, thorough and contained the required documentation. During medication review for 2 residents, LPA observed documentation discrepancies on the centrally stored medication log. LPA observed that some medications did not log the correct start date, expiration date, or quantity of medication received. LPA and Administrator, and Director of Nursing discussed reviewing centrally stored medication log and documentation expectations (deficiency cited, LIC809D, regulation 87465(h)(6))