Ellee Residential Care #2

87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not comply with the section cited above as the facility was not maintained in current Fire Safety regulations which poses an immediate health and safety risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above per interview with the Administrator and request for inservice training logs, facility was not able to provide evidence of intial and ongoing personal rights training for all members of its staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview, the licensee did not comply with the section cited above, the facility has internet access and does not have a internet access device with videoconferencing, camera, microphone dedicated for resident use] which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview, the licensee did not comply with the section cited above, per interview conducted, the facility does not have a internet access plan in place to allow a resident to access it for personal or confidential information with a reasonable level of priivacy which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview, the licensee did not comply with the section cited above the facility does not have a facility plan in place to allow residents to have shared access among all residents in the facility during reasonable hours which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above in that the facility does not have completed LIC308s- Designation of Facility Responsiblity on file designating the authority and responsible staff to manage the facility when the Administrator is not present at the facility which poses/posed a potential health, safety or personal rights risk to persons in care. The Administrator is on call during the day but not present at the facility until the evening.

Based on observation and interview, the licensee did not comply with the section cited above, the facility Admission Agreement does not address the resident's right to Resident Council which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above per tour of the factiity, "Rights of Resident Council" was not observed posted anywhere in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above per review of the Admission Agreement or documents there is no information provided to the resident or family about the right to create a family council which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above, per tour of the facility there was no bulletin board or other posting area for the display of meeting notices, information and news letters which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above per tour of the physical plant, it was observed that the 12 feet deep facility pool had no water at the time of the visit and the netted fence did not meet state or local building codes. The netted fence did not secure the pool or make the pool inaccessible to the dementia resident in care or able to prevent a fall injury which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above per tour of the resident rooms bedroom #3 does not have a closet, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above per tour of the physical plant, the cabinet under the kitchen sink that houses the knives and cleaning solutions and the garden shed that contained a bottle of Round Up Weed and Grass Killer was left unlock during the visit which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above per review of facilty records, Sandra Yemima and Susanty Jakarta both hired on 8/29/23 were cleared on 8/15/223 but had not requested a transfer of their criminal record as of today's visit, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above per review of Resident #2's file there was a blank Admission Agreemnt on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above per tour of the facility, it was observed that there is no auditory device installed on the front door, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above per information obtained that the Facility is payee for Resident# 3's social security benefits and PACE program and has not maintained the the required Surety Bond in the appropriate amount which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above per tour of the physical plant, it was observed that the backyard and side of the facility contained many items such as a vanity, glass sliding doors, mattress, plastic buckets, mirrors, ladders, wooden boards, plastic bins, sinks, mops, brooms, gardening tools that need to be stored away or discarded, over grown grass and weed need to be cut which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation the licensee did not comply with the section cited above per tour of the resident bedrooms. Dressers were not observed in Bedroom #1 and Bedroom #2 which poses/posed a potential health, safety or personal rights risk to persons in care.