Routine inspection·August 13, 2024

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced Annual Required Visit at 11:41 AM. LPA was met by Assistant Administrator Maria Blanco and explained the purpose of the visit. The fire clearance is approved for Six (6) non- ambulatory residents. There is a hospice waiver approved for 3 residents. During today’s visit facility was found to have one (1) bedridden resident without approved fire clearance civil penalties assessed. The facility is located in a residential area. A tour of the single-story facility included: 4 resident bedrooms, 2 resident bathrooms, living room, kitchen, dining area, front yard, backyard, and attached garage. LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. The facility has one (1) fully charged fire extinguishers which is kept in the kitchen. Cleaning supplies and toxic substances were observed to be inaccessible to clients. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Sharps are locked and placed in cabinet in kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The garage was observed to be converted into a bedroom with walls and a closet deficiency cited. SEE LIC 809C Four (4) Staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Six (6) Client files were reviewed and included physicians report, TB clearance. Fire/earthquake drill was conducted on 07/16/2024. Infectious control plan was reviewed. The facility had expired liability insurance deficiency cited. The medications are centrally stored and locked in a cabinet in kitchen The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all clients, and they are being administered as prescribed by the physician. Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Maria Blanco.