Routine inspection·September 21, 2022

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, food, and medication review. LPA Flores met with Larry Ho caregiver and explained the reason for the visit. Ewa Nyczak administrator arrived 20 minutes later. The facility is licensed to serve 3 ambulatory and 3 non-ambulatory residents age 60 and above. Non-ambulatory in ground bedrooms only. Facility is a two story residential home consists of (5) resident bedrooms, (1) staff bedroom, (2) resident bathrooms, (1) staff/guest bathroom, a living room, dining room/ office area, kitchen, laundry area, backyard/ garden that includes lattice with (table and chairs), detached garage for storage purposes. No large bodies of water were observed. LPA Flores conducted a tour of the facility with Larry Ho Caregiver and observed the following: Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Sharps and cleaning supplies are kept in a cabinet next to refrigerator and was unlock at the time of the visit. Small refrigerator in kitchen had resident's medication and not kept under lock. Cleaning supplies were observed under sink in laundry area and accessible to residents. All resident bedrooms have sufficient lighting, furniture and bedding required. Smoke/Carbon Monoxide dectetors were tested and in working condition. Fire extinguisher was observed and last checked on March 2022. Resident bathrooms were observed to have grab bars, skid mats, and are in working condition. Water temperature was tested as follow: bathroom #1(B1) tested at 105.6 degrees F., and bathroom #2(B2) tested at 105.8 degrees F., which is within the required 105-120 degrees F. LPA Flores reviewed medication for 3 residents and files for 4 residents. Resident #1(R1) had PRN medication without a physician's order and medication out of original container. Resident #2 (R2) had PRN medication without a physician's order. Resident #3 (R3) had PRN medication without labels. R3 and Resident #4 (R4) do not have a yearly physician report on file and R4 status is non-ambulatory, R4's bedroom is located in the second floor. Staff files were reviewed and staff #2(S2) does not have a TB test on file. Administrator's certificate #6020655740 expiration date 9/23/24 was observed. (CONTINUED ON LIC 809C) Deficiencies have been noted on LIC 809D per Title 22 Regulations Division 6, Chapter 8. Exit interview was conducted with Ewa Nyckzak administrator and a copy of this report, LIC 809D, technical advisories, and appeal rights were provided.