Routine inspection·October 26, 2023

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 10/26/23. LPA met with the Director of Health Services, Arienne Ghammangne, and explained the reason for the visit today. The facility is licensed to serve 62 bedridden residents ages 60 and above and provides dementia care. The hospice waiver is approved for 10 residents. LPA conducted the inspection using the Compliance and Regulatory Enforcement (CARE) Tools. The following were observed: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff continue to clean and disinfect daily and more often for high touched surfaces. Facility has sufficient PPE supplies and had submitted the Infection Control Plan. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 52 residents residing at the facility. The facility has the sufficient amount for liability insurance covering injury to residents and guests. Physical Plant & Environment Safety: The facility consists of a 2 story building with resident rooms on both floors. The main floor has a lobby, library, bistro area, dining room, kitchen, administrative offices and spacious outdoor patio. The 2nd floor consists mainly of resident rooms and a dining room. There are no swimming pool or bodies of water on the premises. There are no firearms or weapons stored at the facility. LPA selected random rooms - (rooms #121, #119, #157, #163, #216, #221, #256, #260) to measure the hot water temperature. 4 out of the 8 rooms had temperatures between 136-137 degrees F which is over the required range of 105-120 degrees F. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Incidental Medical & Dental: The medications are centrally stored in the wellness office. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. LPA reviewed 5 residents' medication and they are being administered as prescribed by the physician. A deficiency is being issued today. An exit interview was held and a copy of this report along with appeal rights were given to administrator Carpio.