Routine inspection·March 9, 2024

Licensing Program Analysts (LPAs) Emily Peraldi and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. At 9:00 a.m., the LPAs met with staff and explained the reason for the visit. At 9:40 a.m., the Administrator, Anna Bernice D Lee arrived at the facility. Entrance interview. At 9:44 a.m., the LPA along with the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. The facility is a single-story residential home with seven (7) bedrooms, six (6) for resident use and one (1) for staff use and five (5) bathrooms. The property has an attached garage and remains inaccessible to residents. BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. LPA observed a hallway closet with extra towels and linens for resident use. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Starting at 9:47 a.m., the hot water temperature was measured in four (4) resident bathrooms, and they measured between 70.5 and 119.1 degrees Fahrenheit. The Administrator had maintenance adjust water temperature during the time of the visit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing. Continued on LIC-809-C. KITCHEN: The LPAs observed the kitchen and dining area. Knives are stored in an inaccessible kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Food labels were observed for expiration dates. At 10:01 a.m., the kitchen faucet was measured at 111.2 degrees Fahrenheit. Medications are located in a locked cabinet adjacent to the kitchen. A first aid kit is located near the kitchen. OUTDOOR SPACE: At 9:45 a.m., the LPA observed the back patio which has a covered outdoor area with a table and chairs for resident use. There are two gates on each side of the house designated for an emergency exits. The property is gated. Passageways were free and clear from obstruction. There are no bodies of water on the premises. Laundry units and laundry detergents are located inside the garage, which remains inaccessible to the residents. COMMON AREAS: The LPAs observed common areas to be relatively clean and properly furnished. The LPAs observed the fire extinguisher to be fully charged and last serviced on 10/12/2023. At 10:02 a.m., fire alarms/carbon monoxide detectors were tested and functioned properly. All exits have functioning auditory devices and were operational at the time of the visit. Facility telephone was observed during the time of the visit. LPAs observed cameras in the common areas, and throughout the exterior perimeter of the facility. Night lights were present in the hallways. Cleaning solutions, chemicals and hazardous items were inaccessible and locked away inside a locked hallway closet. RECORD REVIEWS: Starting at 9:15 a.m., the LPAs conducted a file review for all residents and staff regularly scheduled and observed the following: Staff have current first aid and training documentation showing required training completed. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. The following was observed: two (2) out of two (2) home health signed written agreements were not present in resident files during the record review. One (1) out of one (1) hospice resident did not have a current and complete hospice care plan maintained at the facility. At 10:40 a.m., the Administrator identified and printed out the above records and placed missing records in resident files. All files were in order. The Administrator’s certificate is active and expires on 01/11/2025. The LPAs requested a copy of valid liability insurance and Facility Emergency Plan and Infection Control Plan. The last emergency disaster drill took place on 03/01/2024. Continued on LIC-809-C. During the time of the visit, the LPAs conducted interviews with one (1) resident. At approximately 11:10 a.m., the LPAs conducted a review of medication and medication documentation with staff for six (6) residents. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.