Facility Evaluation Report

On 3/2/22 at 9:45am Licensing Program Analyst (LPA) Kevin Gould arrived at Enclave at the Delta for the purpose of conducting a required 1 year annual inspection. LPA met with staff, Susan Lo and together conducted a tour of the facility.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 125 degrees F in room 10 and 64 degrees in rooms 7, 5 and the shared bathroom which does not meet the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA observed several cameras in and outside the facility. LPA requested to view the monitor and observed Cameras 8, 9 and 10 had unobstructed views to resident bedroom doors and possible when bedroom doors are open, the interior of the bedroom could be visible.

LPA conducted file review and observed that three staff members did not have criminal record clearance prior to working in the facility. Two staff members are still pending clearance and the third staff member shows as invalid. Additionally, several staff did not have their criminal record clearance associated with this facility but still associated to the a sister facility. LPA conducted a review of the medication administration records (MARs) for residents and observed several days in late February that were not documented in the resident's MAR. Every resident MAR reviewed contained dates not signed off by staff. Staff confirmed the missing dates is due to documentation issues and not resident refusal as she would have been notified and residents reassessed.