Routine inspection·August 20, 2024

Licensing Program Analyst (LPA) Lorena Casillas met with Administrator James Durando for an unannounced one (1) year Required visit for this facility. LPA arrived at 9:30 am and was greeted by caregiver and Administrator. One (1) resident observed in the living room watching TV, one (1) resident in the community, and two (2) residents at day program. LPA informed the Administrator of the purpose of the visit. Entrance Interview conducted. A tour of the physical plant was conducted with the Administrator at 09:50 am. The facility has seven (7) bedrooms and three (3) bathrooms. Four (4) rooms are currently used by residents, one (1) bedroom is used as an office, one (1) room as a storage room, and one (1) room is used as a staff bedroom. LPA observed that staff bedroom was locked, and residents do not have access to it. Infection control: LPA reviewed facility mitigation plan (approved on 04/22/2021) to make sure licensee was following current infection control recommendations. Living and Dining : The facility maintains a comfortable temperature at 70°F. The living room and dining area appeared clean and were properly furnished. No obstructions or tripping hazards throughout the facility. There is a fire extinguisher by the kitchen, and it was last serviced on 12/18/2023. The laundry area was located in a backroom and all chemicals observed to be locked and inaccessible to residents. The washing machine is currently being repaired and a replacement washing machine is being used instead, Administrator states that they are waiting on parts for the broken down washing machine. The replacement washing machine is located in the facility and is functioning properly. Smoke and carbon monoxide detectors were located throughout the facility, and at 10:15 am they were tested and observed to be operational. Continued on LIC-809-C. Kitchen: During LPA’s visit, a repairman was in the facility currently repairing the fridge. A replacement fridge is located in the spare bedroom, it is working properly and is stocked with ample amounts of food. LPA conducted a tour of the kitchen around 10:00 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp objects locked and inaccessible. The medications are stored in a locked cabinet in the kitchen. LPA observed a first aid kit stored in a locked cabinet in the kitchen. Bathrooms: At 10:10 am LPA observed all bathrooms are clean and in good repair. The hot water temperature measured 115.7°F. LPA observed appropriate grab bars and non-skid mats. LPA observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination. Bedrooms: There are four (4) bedrooms designated for residents’ use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Physical environment: At 10:30 am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water. Administrative : Liability/Bond Insurance, LIC500 and client roster will be emailed to LPA. Annual fees are current. Resident/Staff Files : LPA conducted a file review of resident and staff records at 12:00 pm. Medications : At 1:00 pm LPA and Administrator reviewed medication and medication records for proper documentation. Staff Interviews : At 01:30 pm LPA interviewed staff. Client Interviews : At 02:00 LPA interviewed client. There are no deficiencies to report and no citations to be issued. Exit interviewed conducted and a copy of the report was emailed to the Administrator.