Routine inspection·March 27, 2025

Licensing Program Analyst (LPA) Vaid conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Caregiver Yanina Cota. Administrator Hugh He arrived later. The following 12 (CARE) tool domains were utilized during the inspection: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan. 2. Operational Requirements: A current Plan of Operation was reviewed. The facility serves residents 60 years and older, has a Dementia Waiver in place, and a Hospice Waiver for one (1) resident is approved. A fire clearance for 5 non-ambulatory and (one) 1 bedridden resident is place. Liability Insurance in the amount of at least ($1,000,000)/ occurrence and ($3,000,000) in total annual aggregate is in place and expires 7/1/2025 A surety bond is not applicable. Facility does not handle resident's money. 3. Physical Plant/Environment Safety: The facility is a single-story home located in a residential neighborhood consisting of 6 bedrooms; 5 bedrooms for residents (4 private & 1 shared) and 1 staff bedroom, 3 bathrooms, living room/ dining room, kitchen, outdoor covered patio area, laundry area is in the porch, and home has no garage. The facility has one (1) fully charged fire extinguisher 01/15/2025. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There is an empty water fountain located in the backyard. Kitchen drawers containing knives/sharp objects were locked. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Water temperature in bathrooms was 119.7, 118.4, 118.9 and kitchen was 119.3 Deg F. 4.Staffing: A total of 3 caregiver staff provides care and supervision to the clients. Due to printer issues, report will be emailed. CONTINUED ON 809C...... 5. Personnel Records/Staff Training: Administrator certificates expire 8/06/2025. Personnel files/training were reviewed. Staff training, health clearance, criminal background clearance and 1st Aid/CPR training was checked. 6. Resident Records/Incident Reports: A total of four (4) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information. However, Dementia residents (R2- R4) had Physician Reports. RCFE complaint poster and Personal rights were observed posted in the facility hallway. 7. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. 8. Food Service: Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are in place. 9.Incident Medical and Dental: Four (4) centrally stored resident medications were reviewed. Resident (R1) observed to have a 30-day supply of medications. Medical and dental transportation is provided by family, transportation services, or staff. 10. Disaster Preparedness : Emergency and Disaster Plan LIC 610E is in place. The last emergency disaster drill was conducted on 1/13/2025. 11. Residents with Special Health Needs :One resident is receiving home health services. One resident is enrolled in hospice care. Individual Service Plans and Appraisals were observed in resident files. Resident has a G-tube and is enrolled in home health care and health care plan was observed on file. Exit interview was conducted with Administrator Hugh He. A copy of the report was issued. LPA Vaid having printer issues, will email this report to the facility.