Routine inspection·August 7, 2024

Licensing Program Analysts (LPA) Sandra Urena and Erica Mosley arrived at the facility unannounced to conduct a required annual inspection at 10:00 a.m. LPAs were greeted by staff. The Administrator Rolando Lazatin arrived shortly thereafter, and the LPAs explained the reason for the visit. At 10:20 a.m., LPAs, staff and the administrator conducted a tour inside, and outside the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for six residents and two staff. Toxic materials are locked, and out of reach of residents. Upon inspection, at 10:28 a.m., LPAs noticed a box with medications sitting in an area between the living room and kitchen area, and accessible to residents in care. Additionally, LPAs observed three small lighters in a kitchen drawer accessible to residents in care. Water temperature was withing regulation limits. BEDROOMS: Five bedrooms were observed to be furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean and in good condition. Extra linens were observed in the hallway cabinet. COMMON AREAS: The common seating area, and dining room furniture was observed to be clean and in good condition. Fire extinguisher was observed to be purchased on 07/23/2024. The walls and flooring were observed to be clean and in good condition. Continues on LIC 809C… BATHROOM: Bathrooms were observed to be clean; shower area was in clean condition with grab bars, and a non-skid mat available. Hand washing signs were displayed, and enough soap, and paper products in each restroom. Water temperature was withing regulation limits. OUTDOOR: Backyard has a patio area and has patio shade umbrella and patio furniture for residents’ use. No open bodies of water were noted. RECORDS: Records review began at 11:22 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. Two out of three residents’ records were missing an updated appraisal assessment. Two residents’ files were not available for review, licensee stated that the files were damaged by water and licensee was in the process of creating new files. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate annual training. Four out of four files were missing the annual mandated 20-hour training. MEDICATIONS: Medications review began at 1:06 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented in the centrally stored medications and destruction record. No errors were observed during the medication review. INFECTION CONTROL : The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA obtained the following documents: - LIC500 Personnel Report Deficiencies were cited at this time. Exit interview conducted. A copy of the report was issued.