Routine inspection·June 20, 2023

On 06/20/2023 at 08:46 AM Licensing Program Analyst (LPA) David España conducted an unannounced required annual visit. Upon arrival at the facility, LPA España met with Richard De La Rama, Caregiver and Rosana Tan, Caregiver and conducted a risk assessment at the front door and discussed the purpose of the visit. The Manager, Nawal Sfeir arrived at the facility and join us for tour/annual. LPA was properly equipped with Fit tested N-95. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. The facility is licensed for six (6) non-ambulatory residents and an approved hospice waiver for three (3) residents. Currently, there are two (2) hospice residents present during today’s visit. During the tour, LPA observed the facility’s infection control practices. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in a storage room; sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the back patio or front living room. LPA observed required postings throughout the facility. All three (3) residents with memory care needs. All rooms were inspected. Each resident has their own individual room. Beds and bedding supplies were in good condition, adequate lighting provided, storage for residents. Manager, Nawal provided to LPA a copy of Liability Insurance (Certificate of Property Insurance) and Premium Breakdown documentation. There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. A comfortable temperature was observed in the facility. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives were observed locked in storage cabinet. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents in care. The First Aid kit was available. Two (2) fire extinguisher were observed in a box in the corner of kitchen area. Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Doorways were free of obstructions. Facility client records were reviewed. Three (3) staff files were chosen for random review. Staff have criminal record clearances and are associated to the facility. LPA observed water temperature in bathroom(s) #4, #5, #3 was shown to be between 105F and 120F. The following deficiencies were cited: · Staffing - Type B: 1569.618(c)(3) · Personnel Records/Staff Training - Type B: 87412(a) · Resident Records/Incident Reports - Type B: 87507(a)(1) · Resident Rights/Information - Type B: 87468(c)(2)(A) · Disaster Preparedness - Type B: 1569.695(a)(1) · Residents with Special Health Needs - Type B: 87618(b)(3)(A) An exit interview was conducted, and a copy of this report and citation was provided to Manager, Nawal Sfeir and Administrator, Tanios El Habar.