Routine inspection·September 14, 2023

On 09/14/23 Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. Upon arrival, LPA was greeted by staff and explained the reason for the visit. Shortly after, LPA met with Rodolfo Espino. A tour of the physical plant was conducted at 10:15AM. The facility has 6 bedrooms. Bedrooms: Five (5) bedrooms designated for residents' use and (1) bedroom designated for staff. All bedrooms were clean, properly furnished and had sufficient lighting. Common Areas : This includes the living room dining areas were appropriately furnished and lighting was adequate. LPA observed medication cabinet to be locked and inaccessible to residents. The living room has a television and comfortable furniture. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA observed that sharp objects were stored in locked drawers and cabinets. LPA observed fully stocked first aid kit in the kitchen the fire extinguisher purchased date 08/24/23. LPA found a sufficient amount of perishable and non-perishable food at the facility. Temperature: Facility maintains a comfortable temperature of 80 degrees Fahrenheit. Bathrooms: There were three (3) bathrooms in the facility. One (1) bathroom in hallway which is the main and two (2) bathrooms in the private bedrooms. All bathrooms were clean, properly supplied and had functional fixtures. All chemical cleaners were locked under the sink cabinet. Laundry Area: located through the kitchen. Appliances observed to be in good repair. All cabinets were locked and thus laundry detergents were inaccessible to residents. Backyard Area : There is a clean covered shaded area in the back yard and there is a pool which has a gate and is kept locked and inaccessible to residents in care. LPA also observed another room outside in the backyard next to the pool that has a hospital bed and a private bathroom. This room was not indicated on the facility sketch during the application process, which posed a potential health and safety issue for residents in care. Garage: LPA observed the garage been converted to a room with private bathroom. Review of facility sketch does not indicate that there is a room created in the garage. Interview with administrator revealed that the room was built during COVID for staff for isolation in case of contact. During records review LPA observed Tramadol medication over the number that stated on the container. Interview with administrator revealed that Administrator has transferred old Tramadol medication to the new container. Exit interview conducted and a copy of the report and appeal rights were provided. Deficiency was cited on 809D.