Routine inspection·September 16, 2023

Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspection. LPA was allowed entry by Violeta Necesito (Caregiver) and Jorgen Deleon (Caregiver) and explained the purpose of today's visit. Administrator, Irene Deanon arrived at 10:30am and assisted LPA with the inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility. The facility has submitted a COVID-19 Mitigation Plan and was reviewed. Facility has not developed and submitted the infection control plan to CCLD. Administrator agreed to develop and submit the Infection Control Plan to CCL. Facility has COVID-19 signage posted in the facility. Common area surfaces are being cleaned and disinfected on a regular basis. Staff are adhering to infection control requirements. Operational Requirements : Administrator cannot find and provide the plan of operation to LPA for review. Liability Insurance policy (policy # 00105792-3) in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 7/29/2024. There was no proof of Fire and Disaster Drill which was to be conducted on a quarterly basis. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the persons with special needs were observed. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that is licensed to serve 6 non-ambulatory residents ages 60 and over, of which six (6) may be bedridden. Hospice waiver for 6 was approved. Current census is five (5) non ambulatory, one (1) ambulatory, two (2) are under hospice care and one (1) is bedridden. Home consists of five (5) resident bedrooms, one (1) office room, three (3) bathrooms, living room, dining room, staff lounge area, kitchen, backyard, and a detached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has two (2) fire extinguishers which were last inspected on 5/04/2023. Cleaning supplies and toxic substances are inaccessible to residents. At 10:05am, hot water temperature readings measured 113.9 deg F in bathroom #1, 114.9 deg F in bathroom #2 and 116.4 in bathroom #3 which are within the required 105-120 degrees Fahrenheit. ***CONTINUED ON LIC 809-C** Staffing: A total of eight (8) caregivers including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. Personnel Records-Training: Administrator certificate expired on 6/11/2023. However, Administrator stated that she submitted her renewal in May 2023 and finished all the required courses. Administrator awaits for the actual Administrator certificate. Three (3) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and First Aid/CPR training. Resident Records-Incident Reports: Three (3) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed. Resident Rights-Information: Resident personal rights are posted. Physician orders for use of full bed rails were reviewed in five (5) residents files. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. However, Administrator did not have planned activities in place or posted in the facility. Administrator did not have planned activities in place for residents in facility. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Incident Medical and Dental: Five (5) residents have Restricted Health Care Plan and Needs and Services Plan on file. Home Health personnel service four (4) residents in the facility. Residents medication are centrally stored in a locked cabinet in the kitchen area. The first aid kit has missing items like thermometer, tweezers, manual, adhesive tape, etc. Additionally, the kit contained expired BENDARYL itch stopping cream and NEOSPORIN antibiotic pain relieving cream, both creams expired on 05/2021. LPA reviewed two (2) of the residents (R1 & R2) medications and observed that Pravastatin Sodium (10mg) and Citalopram HBR (10mg) were prescribed to be given in the AM, but Administrator & staff administer the medicaitons in the PM. Additionally, one of the medications for R2 was administered but the staff did not properly document the MAR and did not indicate that the medication has been administered. Disaster Preparedness: The facility has not conducted an emergency drill on a quarterly basis for all staff and residents. Administrator cannot provide LPA a copy of the Emergency and Disaster plan for review. Residents with Special Health Needs: Administrator has not made a report in writing to the local fire department that oxygen is in use at the facility and facility has bedridden residents. Administrator stated that staff have not received training regarding operation of the oxygen equipment. Pursuant to Title 22, deficiencies were cited on the attached 809D. Exit interview conducted, appeal rights provided, and copy of report were provided to the Licensee/Administrator, Irene Deanon.