Routine inspection·April 10, 2025

Licensing Program Analyst(s) (LPA)s Mary Flores and Blanca Gonzalez conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Jacqueline Hernandez Business Services Director and explained the reason for the visit. Facility is licensed to served 206 elderly residents age 60 and over, ambulatory and non-ambulatory. Rooms excluded from non-ambulatory status are #110, 221, 222, 243. The facility is a two story building located in a residential neighborhood. It consist of several resident bedrooms in both floors, a lobby seating area, offices, a dining room, a coffee bar, a studio dining room, a commercial kitchen, a medication room, a common shower, an activity room, a family room, a parlor, a courtyard in the first floor, a conference room, a TV room, a library, a laundry room, and patio in the second floor. LPA reviewed the following CARE inspection tool domains during this visit: Infection Control: Infection control plan was reviewed which meets current regulations and was last revised on 5/12/24. Hand sanitizer and proper sanitation were observed during the visit throughout the facility. There is a responsible person and emergency training was provided to staff. Personal protective equipment was observed. Staff have a TB test clearance on file. Operational Requirements: Facility maintains a plan of operation. Facility has a current liability insurance. Facility is operating within the license. Physical Plant/Environmental Safety: LPAs conducted a tour of the facility with Jacqueline Hernandez and observed the following: Facility was observed clean and in good repair indoors and outdoors. (CONTINUED ON LIC 809C) First Floor: Lobby, family room, TV room, dining room, coffee bar, beauty parlor are clean and in good repair. Fireplace was observed in the lobby and it was adequately screened. Kitchen was observed clean, with hot water temperature warning sign. Emergency food supplies were observed in a closet by the kitchen. Wellness room was observed inaccessible to the residents. Common shower across from the elevator has skid flooring. Four resident bedrooms were observed in the first floor, each with sufficient lighting, required furniture and bedding supplies. The residents bathrooms were clean and in working condition with grab bars, and skid mats. Water temperature was tested between 108.8-112.4 degrees F. Second Floor: Library's fireplace is adequately screened. Library, conference room, and sensory room were observed clean and in good repair. Five resident bedrooms were observed in the second floor, each with sufficient lighting, required furniture and bedding supplies. The residents bathrooms were clean and in working condition with grab bars, and skid mats. Water temperature was tested between 105.0 - 113.5 degrees F., which is within the required 105-120 degrees F. Passageways were clear of obstructions. Courtyard has shaded seating area for residents. Staffing: Administrator Anabelle Argenal arrived at the facility shortly after. At least one person on shift has current CPR/First Aid training on file. There are 4 available night staff, whom have been provided emergency training. Sufficient staff were observed. Personnel Records/Staff Training: Administrator certificate for Anabelle Argenal #6034626740 was observed exp. date: 4/21/25. All staff records were available for review. LPA reviewed a total of 4 staff files which included medical assessment, TB clearance, background clearance, and training. Staff training files were reviewed, training has been provided on Hospice, Restricted Health Conditions, and Postural. As well as dementia, emergency, and activities of daily living. Resident Rights/Information: Personal Rights, Let Us No poster (PUB 475), and Local Ombudsman posters were observed in the lobby. Planned Activities: Activity materials were observed, for activities such as religious, clubs, exercises, and gardening. Outdoor area has a seating area to promote outdoor activities. The facility has a library and a sensory area to stimulate neurological skills. Food Service: Sufficient food supplies were observed of perishables for at least 2 days and non-perishables for at least 7 days. Commercial food supplies were observed. The list of residents with special diets was posted in the kitchen. Pest was not observed. Staff were observed using hygiene and contamination prevention methods. (CONTINUED ON LIC 809C) Incidental Medical and Dental: Wellness room is used to stored in house medications, refrigerated medications, and surplus medications. Medication carts are located in the studio dining room and were observed locked. Medications are label and in their original containers. LPAs reviewed medications for 5 residents. Resident Records/Incident Reports: Residents records were available for review. LPA reviewed a total of 5 resident files which contained medical assessment, TB clearance, admission agreement, an appraisal, a needs and care plan. Disaster Preparedness: Emergency Disaster plan (LIC 610E 3/19), it has been reviewed within a year. Last Emergency drill was conducted on 3/5/25, quarterly emergency drills are being conducted. Emergency evacuation chairs were observed at the top of each exit door. Residents with Special Health Needs: Postural support/bed rails were observed and physician's request were observed in residents files who are under hospice. Facility is following dementia regulations. Facility has a fenced pond/water feature in the courtyard. Medical assessments for residents with dementia were observed within the last 12 months. All egress exit doors were tested and are in working condition. Facility keeps hospice plan on file. No deficiencies were noted during this visit. Exit interview was conducted with Administrator and a copy of this report was provided.