Routine inspection·September 12, 2023

On 09/12/2023 at 11:05 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Liza "Gigi" Elegado and explained the purpose of the visit. The facility’s fire clearance was approved for 49 Resident capacity in which all may be non-ambulatory. Approved hospice waiver for 10 Residents. LPA toured the facility with Gigi including but not limited to 4 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 76 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 140.3 and 141.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. At 12:45 PM, LPA reviewed 10 Residents records. At 3:00 PM, LPA reviewed 7 Staff records and 7 of 7 have current first aid training but all 7 staff were associated to the facility. LIC809 Continued.... LIC809 Continued Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/19/2023: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Updated Facility Sketch Liability Insurance Current Administrator’s Certificate No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.