Routine inspection·May 18, 2023

Licensing Program Analyst (LPA) Tuesday Cabiness a required annual inspection. LPA met with the Administrator Alfredo Rapisura and informed him the reason of the visit. The current census is six (4). Facility license, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, and neighborhood complaint procedures, and COVID related signs visibly posted. A physical plant tour of the facility inside and outside was conducted. The following common areas: living, dining, kitchen, family, resident/staff rooms, and bathrooms were inspected to ensure the facility was in compliance with Title 22 Regulations: Kitchen/Food Supply: Food service area had Licensing requirement of (7) day nonperishable, and (2) day perishable. Food was properly stored in a healthy manner. Food storage and preparation areas were clean and inaccessible to pests. Appliances were functional and clean. Chemicals, household supplies, and knives, and medication was locked and secured in the kitchen and garage area. Living/dining/family/staff area: All indoor passageways were free from obstruction; and all areas were clean and appropriately furnished for resident’s comfort. Bedrooms: The facility has six (7) bedrooms and (2) bathrooms currently occupying six (4) residents; with one (1) bedroom is designated for staff use. LPA also observed in the garage area, and additional built new room for staff. The new building was not approved by Licensing and does not match the original facility sketch that was originally submitted to Licensing. A citation will be issued due to altering the existing building without approval from Licensing. Bathrooms: The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was checked. There was enough clean linen available in stock at the cabinet. Surrounding Grounds: Smoke alarms and carbon monoxide detectors were tested and operating properly. Fire extinguisher is fully charged. The facility is equipped with fire sprinkler, that is connected to the fire department. There were no visible hazards, and passageways were free from obstruction inside of the facility. Backyard has a covered patio with appropriate seating for residents when sitting outside. The swimming pool is appropriately fenced and was observed to be locked during visit. Record Review : LPA reviewed (1) resident file, and observed R1 with dementia to not have current physician report. The report reviewed was dated 07/2019. Staff file review: Staff #1 (S1) did not have current CPR/First Aid certificate. It was expired in 2021. This poses a potential health and safety risk to residents in care. Exit interview, citations, appeal rights and copy of report provided.