Routine inspection·May 3, 2024

Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Executive Director/Administrator Rosario Munoz. The facility is licensed to serve for a capacity of 41 residents (34 Ambulatory and 7 Non-Ambulatory only) ages 60 and above. (2) residents receiving hospice care, (2) bedridden and (2) dementia. LPAs observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Dementia plan has not been added to the Plan of Operation. A Hospice Waiver for 6 is approved.Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 07/30/2024. Surety bond of $5,000.00 is current. The facility was not able to provide LPAs the appropriate fire clearance approved by the city for retaining bedridden and dementia residents. Physical Plant/Environment Safety: There are 6 different cottages (Lambert, Ramona, Foskett, Shafer, Armstrong, Braemar, and Jameson) and each contains resident rooms, living room, small dining room, kitchen, and a laundry room. The main dining room and kitchen are located at the Armstrong building. LPAs randomly selected 6 resident rooms to inspect. They are clean and have the required furnishings. There are no items obstructing the walkways. LPAs observed that the fireplace in Schafer Cottage was not adequately screened. Housekeeper put up the fireplace screen during the visit. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. No large bodies of water were observed. There are no security bars or weapons on the premises. The facility has central air and heating accommodations. LPAs observed cameras in the common areas and audio was accessible in the dining area. The signal system was tested in various locations and is operable. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. Storage areas for cleaning solutions, toxics, knives, and hazardous items were secured and made inaccessible to Residents. The fire extinguishers were observed to be fully charged and in compliance. The facility has carbon monoxide detectors in each cottage. A shaded area with chairs is provided to the residents. *****CONTINUED ON LIC809-C***** Staffing: A total of 24 staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records/Staff Training: Administrator certificates expired on 04/06/2024, however, renewal was submitted and proof that it was received on 02/21/2024 was provided to LPAs. Staff have criminal background clearance and training. Five (5) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training are current. Resident Records/Incident Reports: A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, Individual Needs/Service Plans, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, medication records, and P & I money records. RCFE complaint poster and Personal rights were observed posted. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted in the dining room and in each cottage. The facility has a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Sanitation practices and kitchen cleanliness was observed. LPAs observed a bottle of bleach in the food pantry. Incidental Medical and Dental: Medications are centrally stored and locked in the med room located in the Jameson cottage. Five (5) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. There were deficiencies found during today’s inspection. Deficiencies cited on LIC 809-D, technical assistance and technical violation were issued. An exit interview was conducted, and a copy of this report was provided to Rosario Munoz, Executive Director.