Routine inspection·January 21, 2025

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Lydia Pabion and explained the reason for the visit. 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, a medication room, a laundry room, front porch, and smoking area in the back. LPA conducted a tour of the facility with Jose de Leon and observed the following: Building is in good repair inside and outside. Lobby area was observed poster for Local Ombudsman and personal rights were observed in this area. Activity area is clean, fireplace is inaccessible to residents. Dining room was observed in good repair and clean. Kitchen was observed clean, storage of food supplies was observed with sufficient perishables for at least 2 days, and non-perishables for 7 days. A list of special diets was observed posted in the kitchen. LPA observed 6 random resident rooms and observed sufficient lighting, furniture, and bedding supplies. Each room has a bathroom and were observed in working condition. Water temperature was tested between 111.9 - 126.8 degrees F. which is not within the required 105-120 degrees F. Grab bars were not observed in room #121. Skid mats/strips were not observed in rooms #216 and 224. Ramps, and stairways were observed clear of obstructions. Both stairways were observed with an evacuation chair. Courtyard provides shaded sitting area, front porch provides sitting area, and back area provides a smoking area. Carbon monoxide/Smoke detectors were observed throughout and the facility has a fire sprinkler system. Fire extinguishers in hallways in each floor and last checked on 1/2/24. Last fire drill was conducted on 9/22/24. Additional linens, and cleaning supplies were observed in a closet. Sharps and chemicals were observed inaccessible to the residents. No large bodies of water were observed. LPA reviewed medication for 5 residents and files for 6 residents, of which one was under hospice and hospice plan was observed. Six staff files were reviewed. (CONTINUED ON LIC 809C) Each staff have 20 hours of training on file. Administrator certificate was observed for Lydia Pabion #6006152740 exp. date: 8/10/25. Emergency disaster plan and infection control plan were reviewed and have been reviewed yearly. First Aid kit was observed. LPA interviewed 4 residents and 4 staff. Deficiencies have been noted on LIC 809D per Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.