Routine inspection·June 13, 2024

Licensing Program Analysts (LPAs) Daniel Konishi and Christine Wong, conducted a required annual inspection using the Inspection Tool. LPAs met with the Manager, Tiffany Sasada and the purpose of the visit was discussed. Infection Control: The facility has a Infection Control Plan in place. Personal Protective Equipment (PPEs) were observed. The facility continues to practice hand washing and disinfecting. Operational Requirement: Hospice Waiver for 1 is approved. A fire clearance is in place. Liability Insurance in the amount of at least ($1,000,000.00) per occurrence and ($3,000,000.00) in total annual aggregate is in place and expires 07/11/2024. Structure/Physical Plant: The facility is part of a single-story home located in a residential area and contains the following: living room, dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage kitchen cabinet for sharps, (3) resident rooms, (2) bathrooms for residents; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for resident use. There’s a laundry area; with washer and dryer. The residence is equipped with central air conditioning. There is an inaccessible fireplace. Adequate accommodations observed throughout facility. Hallways f ree and clean of obstruction and debris. All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. All bathrooms have a working toilet, wash basin, shower, grab bars and nonskid mats. Smoke and Carbon Monoxide Detectors Electrical & connected. Battery operated & working, all detectors tested and operational. Toxins are locked/stored for staff use only. Hot Water temperature measured between 109.5 -113 degrees which is within Title 22 Regulation. Staffing: There is sufficient number of staffing. Personnel Records/Staff Training: LPAs reviewed two (2) staff files but Staff #1 does not have health screening, TB Test result and not associated with the faciltiy, and LPA was not able to review staff training hours. Administrator's RCFE Certificate is effective through 06/17/2025. Resident Rights-Information: Resident personal rights is not posted. Per Administrator, facility provides internet services to all residents and have access to the facility phone. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility has a Resident Council. Facility provides equipment and space to accommodate both outdoor and indoor activities. Food Service: All food and adequate utensils such as, dishes, cups, bowls, and plates observed . Sufficient food supply and emergency food supplies are stored in the kitchen. Incidental Medical and Dental: Four (4) centrally stored resident medications inaccessible to residents were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. First aid kit observed. Resident Records/Incident Reports: Resident files are maintained at the facility. A total of four (4) resident files were reviewed. They contained admission agreements, Physician's Reports, TB clearance. One of the resident was missing the pre-admission appraisal. RCFE complaint poster were observed posted on the wall near the dining area. LPAs did not observe any resident's personal right posted in the facility. Disaster Preparedness: The facility does not have an updated Emergency and Disaster Plan LIC 610E in place . Records of resident Appraisal and Needs services plans are part of Emergency training. Residents with Special Health Needs: Currently, one (1) resident is on hospice care and one (1) resident is on home health. Half bed rails for mobility assistance were observed in some resident beds but no physician order in residents' files. Deficiencies are being cited per Title 22 Regulations. See 809-D page. Exit Interview conducted with Tiffany Sasada and a copy of this report and appeal rights discussed and provided.