Routine inspection·June 19, 2023

This is a corrected version of previous Annual Visit dated 01/28/23. LIC 809-D page was amended to correct deficiency from "Type A" to "Type B" for 87303(e)(2) only. Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required Annual Visit on 01/28/2023 at 9:25 am. LPA was met by Licensed Vocational Nurse (LVN) Gloria Madrid and Activities Director Roxana Deleon. Administrator Lydia Pabion was notified by phone of LPA’s visit. LPA requested and obtained a copy of Personnel Report (LIC 500), Resident Roster (LIC 9020) and copy of Liability Insurance. Facility is licensed to served 99 adults over the age of 60 years old, of which 35 may be non-ambulatory. Facility has a hospice waiver for 4 and the following rooms are cleared for bedridden residents; 102 thru 110, 115 thru 119, and 123. Facility is a two-story building with a commercial kitchen, a dining room, an activity room, a courtyard, medication room, and front porch. No large bodies of water were observed. Sprinkler fire system throughout the facility. Fire extinguishers in hallways in each floor were observed to fully charged. LPA OBSERVATIONS: Tour was given by LVN Madrid at 9:40 am. TV Room: was clean and had sufficient seating and tables. Kitchen: Staff was observed to be wearing masks, hair nets and gloves while preparing lunch for residents. LPA observed kitchen to be clean and appliances appeared to be in working order. Walk in refrigerator was observed to contain sufficient food supply for 2 days of perishables and 7 days of non-perishables and a temperature reading of 40 degrees F. Walk in freezer was clean and a temperature reading of 0 degrees F. Kitchen sink water temperature was measured at 184.1 degrees F. No warning sign posted above this sink or any other kitchen sink in kitchen area was observed. Signs promoting hand washing and social distancing were observed. Dining Room: Dining room area was clean, and tables were spaced out to promote social distancing. Signs promoting social distancing and cough/sneeze etiquette were observed throughout dining area. LPA observed a corner area of dining room to have several stacked dining room chairs, rectangle bbq grill, empty grocery cart, 4ft standing fan, boxed Christmas tree, and a beige serving cart to be cluttered in the corner of the room. Per LVN Madrid, the facility is using this area to store excess chairs until they can find another place to store them. Resident rooms 1 st floor Non-Ambulatory: Rooms # 101 and 104 contained the required lighting, furniture, and linens. Water temperature in Room # 101-bathroom was measured at 106.2 degrees F and room # 104 water temperature in bathroom was measured at 107.8 degrees F which meets Title 22 Regulations. Room #108 is a shared room. Room #108 contained required lighting, furnishings, and linens. Bathroom contained skid matts and grab bars. Water temperature was measured at 99.8 degrees F which is does not meet Title 22 Regulations and poses an immediate health, safety, or personal rights risk to persons in care. Cabinet doors in bathroom are missing knobs and right cabinet door is cracked from top to the side of door. Resident rooms 2 nd floor Ambulatory: Resident room # 201 contained required lighting, furnishings, and linens. Room was clean and LPA observed hand sanitizer nearby. Water temperature in bathroom was measured at 96.8 degrees F which does not meet Title 22 Regulations. Resident room # 209 contained required lighting, furnishings, and linens. Room was observed to be clean. Water temperature in bathroom was measured at 95.4 degrees F which does not meet Title 22 Regulations. Resident room # 220 contained required lighting, furnishings, and linens. Room was observed to be clean. Water temperature in bathroom was measured at 99.1 degrees F which does not meet Title 22 Regulations. Resident room # 223 contained required lighting, furnishings, and linens. Room was observed to be clean. Water temperature in bathroom was measured at 110.4 degrees F which meets Title 22 Regulations. Front lobby and Courtyard: Clean and free from hazards and clutter. LPA observed plenty of seating, tables and shade for residents and visitors. Staff and Resident Interviews: 3 staff and 3 residents were interviewed between 10:45 am and 11:15 am. Administrator certificate was observed for Lydia Pabion #6006152740 expiration date: 8/10/23. Last fire drill was conducted on 01/2023. A technical violation and deficiencies were cited during visit. Exit interview was conducted with Activities Director Deleon and a copy of this report, LIC 809D, LIC 9102, and appeal rights were provided.