Routine inspection·October 15, 2024

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Staff Henry Scott and explained the reason of the visit. The following domains were completed during the visit: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility still practice hand washing constantly. The facility has submitted an Infection Control plan in place. 2. Operational Requirement: The facility is licensed to serve elderly residents age 60 and above. Fire clearance granted for six (6) ambulatory residents only. Currently all the residents are ambulatory. Liability Insurance documentation was not provide to LPA during the visit. Facility does not serve residents with Dementia. 3. Physical Plant and Environmental Safety: The facility is a single-story home located in a residential area. A tour of the facility includes: 2 living rooms, dining area, kitchen, laundry room with pantry, (4) bedrooms of which (1) is a designated staff room, 3 bathrooms ( of which 1 is attached to the Staff room), back yard with required shaded area and outdoor furnishing. LPA inspected all three resident bedrooms: required furniture and beddings were observed as well as sufficient lighting and closet space. Bathrooms observed to be clean, sanitary and in a good working condition. The bathroom also has required grab bar and non-skid mat. The hot water temperature tested in resident bathroom is 119 degrees F which is within the Title 22 regulation. The toxic cleaning supplies are stored and inaccessible to residents. The facility has a land line telephone system. Fire alarms and C02 alarms observed. The walkway, passageway and patio are free of obstruction. 4. Staffing: The facility has sufficient staffing in the facility. Staff has updated CPR training. The administrator and care giving staff live in the facility; therefore staff is available and present overnight. Continued on LIC 809-C 5. Personnel Record Training : All the staff files are stored. The facility staff are all over 18 years old, associated with the facility and criminal background clearance. The facility administrator is Samantha Alex and her administrator certificate is expired. 6. Resident Records-Incident Reports: The resident files are centrally stored. LPA reviewed four (4) resident files and they all have the required documents which included: face sheet, pre-placement appraisal information, appraisal/needs and service plan, admission agreement, updated physician report and TB test, ambulatory status and medication list. Two (2) Resident files were not present for review. 7.Residents' Right : The facility has all the required postings. The facility also has internet service shall provide at least one internet access device for resident use to face time with their families or entertainment. 8. Planned Activities: The facility does have sufficient space to accommodate both indoor and outdoor activities 9. Food Service: The facility has sufficient food supply for two days perishable and seven days non-perishable. All the food are stored probably. No residents are on modified diet that prescribed by the doctor. 10. Incident Medical and Dental: The resident medication are centrally stored and locked in the kitchen cabinet. LPA inspected all six (6) residents medications on hand. Centrally stored medication list for (2) of (6) residents were not completed to match prescription orders. Administrator will also provide medical and dental transportation if needed. 11. Disaster Preparedness: The facility has a disaster plan in place. The facility has two alternative temporary shelter location. Facility was provided notice to update the disaster plan to the updated form provide by the department. 12. Residents with Special Health Needs: There is (1) resident with home health services. LPA reviewed and observed the home health file. There are no residents on hospice. No resident is under restricted health condition or prohibited health condition. Per the completion of the Inspection Tool, deficiencies are being cited for todays visit. Please see attached 809-D pages. Appeal rights discussed and provided. Exit Interview conducted and a copy of the report was provided.