Facility Evaluation Report

On 8/7/23 at 9:34 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. LPA met with Licensee/Administrator (LIC) Rachael Gardiner.

LPA toured inside and outside the facility. Facility set at comfortable temperature. Smoke and carbon monoxide detectors tested and operational. All bedrooms observed with sufficient furnishings and lighting. Non-skid mats observed in showers. Grab bars observed for each toilet and shower. Smoke and carbon monoxide detectors tested and operational. Sharps observed locked. Centrally stored medication observed locked. Staff and resident records reviewed. Administrator certificate valid.

The following deficiencies were observed:

1. Fire extinguisher last serviced on 6/3/21.

2. A bottle of toilet cleaner observed accessible in bathrooms 1 and 3; cabinet where all chemicals and cleaners are stored was accessible and stored in accessible laundry room; and various paint can sizes observed accessible in open cabinet in accessible garage.

3. S1 did not have a completed transfer of criminal record clearance and has been working in the facility since 6/28/21.

4. Bathroom #2 observed with curtain in doorway and door missing.

5. R2 does not have TB results and was admitted to the facility on 7/24/23.

6. Residents' medications were observed prepared in advance of five days in a separate week pill box located in the inaccessible kitchen drawer where sharps are stored.