Routine inspection·July 9, 2024

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a required annual inspection. LPA met with caregiver Mario Ilagan, who was informed the reason of the visit. LPA was allowed to enter, and observed residents in the living room, and (2) additional staff on duty. Caregiver contacted Administrator's son, Allen Rapisura who was informed the reason of the visit. Administrator Alfredo Rapisura was contacted, and LPA spoke to him over the phone; he was also informed the reason of the visit. Allen Rapisura arrived shortly after. Also, caregiver Allen's family arrived with wife and (2) daughters, and during personnel summary check, the wife was not associated or fingerprint cleared. A civil penalty will be issued for not having fingerprint clearance or association. The current census is six (6). 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 not properly stored in a healthy manner. Food storage and preparation areas were opened and not clean which could lead accessible to pests. Appliances were functional and not clean. Walls were dirty in the kitchen, hallway and bathroom. 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 (6) residents; with one (1) bedroom is designated for staff use. During last year's inspection on 05/18/2023, LPA observed in the garage area, an additional built new room for staff. The new building was not approved by Licensing and did not match the original facility sketch that was originally submitted to Licensing. A citation was issued; and facility was to submit there plan of correction. During today's visit, LPA observed the same additional room, which was called a "break room" for staff, but it did not have approval by the city to be built. An additional citation for the same deficiency will be issued; due to altering the existing building without approval from Licensing, and not obtaining a proper fire clearance for bedridden residents. Also LPA observed resident # 1 (R1) who was admitted to the facility on 07/04/2023, with a prohibited health condition, a colostomy bag. An immediate $500 civil penalty will be assessed for retaining residents that are bed-ridden and not having a proper fire clearance. An additional $500 will be assessed due to the facility retaining a resident with a prohibited health condition. 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. 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 (5) resident files, and observed R1-R5 were missing important Licensing documents, such as physician reports, needs and service plans, functional capabilities, re and pre-appraisal documents, and residents diagnosed with dementia, without a current physician report. Staff file review: Staff # 2 is missing a health screening report; other documents reviewed and checked. This poses a potential health and safety risk to residents in care. Medication review: Exit interview, citations, immediate civil penalty, appeal rights and copy of report provided. Total amount of civil penalties issued during this visit $1100.00