Routine inspection·November 15, 2023

Licensing Program Analyst (LPA) Sandra Urena arrived unannounced to conduct a required annual visit. The LPA met with Administrator Doris Almario and explained the reason for the visit. The LPA and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply for two days of perishable and a seven day supply of non-perishable food. The hot water temperature measured at 109.8 degrees Fahrenheit. Laundry room is adjacent to the kitchen. Washer and dryer were functioning at the time of the inspection. Cleaning supplies and disinfectants are kept in locked cabinets in the laundry room. BEDROOMS: The facility has six private resident bedrooms and one staff room, all which were furnished appropriately; beds had clean linens and rooms had sufficient lighting. All direct exits were clear, and no obstructions were noted. RESTROOMS: Three out of six resident rooms have a private restroom inside the room and three have restrooms outside the rooms. One common restroom is located by the laundry room. The restrooms were clean and sanitary with grab bars and non-skid surfaces. Water temperatures measured between 105.5- and 109.3-degrees Fahrenheit. Restrooms were fully stocked with hygiene paper and paper towels. Hand-washing signs were observed. COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 73 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The two (2) fire extinguishers were fully charged and were last serviced on 10/15/2023. The LPA observed required postings throughout the common space. Continues on LIC 809C... OUTDOOR AREA/GARAGE: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single latched. No bodies of water noted. The garage is attached to the facility with a connecting door. Door was locked at the time of the visit. RECORDS: Records review began at 11:30 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 1:00 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors were observed during the medication review. INFECTION CONTROL : The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster -Liability Insurance -Emergency Drills Form No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.