Routine inspection·August 7, 2022

On 08/07/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with assistant administrator Anchie Reyes and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for two (2) hospice residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident's rooms, two (2) common bathrooms, living area, dining area, kitchen, a staff room, and outside covered patio area. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be clean and operational. The water temperature measured 107.6 F. A comfortable temperature of 73 degrees was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. The facility has two (2) fire extinguishers that were charged. A working landline telephone remains available. Evaluation Report Continues on LIC 809-C INFECTION CONTROL: During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff tests and residents' vaccination along with daily temperature checks were conducted. The facility has an approved Mitigation Plan Report on file with CCLD. DEFICIENCIES: During a health and safety inspection, LPA observed at 3:01 pm a cleaning solution on top of the toilet in bathroom #1. LPA identified at 3:07 pm, shower floor in bathroom #1 unsanitary with black marks. During record review, LPA observed resident #2 admitted on 07/05/22 as a hospice resident. This exceeded beyond the conditions and limitations specified on the license. The facility is licensed for (2) hospice waivers and currently, the facility is operating with (3) hospice residents in care. Due to time constraints, an annual continuation is required to complete a health and safety inspection at a later date. Deficiencies are issued and an exit interview is conducted with Anchie Reyes. A copy of this report is provided along with the appeal rights.