Routine inspection·April 22, 2024

At 12:33 PM, Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA were greeted by the staff, Elvis Martinez, who granted access to the facility. Later, LPA met with the Administrator designee, Dania E. Baeza, and LPA explained the reason for the visit. At am, LPA conducted a tour of the facility, and the following was observed: Kitchen: At 12:50 PM, LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents. LPA observed a sharp scissor in the kitchen drawer accessible to residents in care. The Administrator designee immediately locked the scissor with other sharps in the kitchen. There is a fire extinguisher in the kitchen, and it was last purchased on 03/25/2024. Medications: At 12:52 PM, LPA observed First Aid Kit complete with the required items as per Title 22 Regulations. LPA also observed medications are centrally stored, and locked in the kitchen cabinet; however, review of R1's random medication revealed that the facility was supposed to start Quetiapine Fumarate 50 MG (Depression Medication) new bubble pack on 04/01/2024. During today's visit LPA counted R1's medication and it was discovered that there was a discrepancy and one (1) extra pill was in the pack. LPA asked the Administrator designee for explaining and they could not provide any answers. LPA also observed Centrally Stored Medication (LIC 622) records and did not observe when the medication start date. A deficiency will be cited. Continue on LIC 809C Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. Facility is licensed for one bedridden resident; however, during the tour that there are three bedridden residents residing in the facility in bedroom # two (2), bedroom # four (4), and bedroom # five (5). All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational . Staff bedroom is located by the living room and LPA observed staff room to be free of obstruction or hazard. Bathrooms: At 1:08 PM, LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 111.5°F. LPA observed appropriate grab bar and non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination. Common Areas : The facility maintains a comfortable temperature at 75°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Outside areas: At 1:10 PM, LPA toured the outside area of the facility. LPA also observed a clean covered patio and backyard furniture to accommodate the six (6) residents . LPA observed sharp gardening tools accessible and unlocked to residents in care. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. The garage: The detached garage is being used for an extra storage and was observed to be locked. Laundry : Laundry area is located by the kitchen/dining area and was observed to be unlocked and accessible to residents in care with all toxins (laundry detergents). Continue on LIC 809C Smoke detectors/carbon monoxide . Dual smoke and carbon monoxide detectors were located throughout the facility, and at 1:20 PM, they were tested and observed to be operational. Between 2:15pm to 3:45pm, LPA reviewed records of six (6) residents and zero (0) staff. Two (2) out of six (6) files were missing identification information, and two (2) out of six (6) resident did not have current physician report on file. Administrator could not provide any staff files to LPA for review. Administrative: LPA collected Certificate of Liability Insurance and LIC500. Citations issued on LIC809-D during this visit. Exit interview conducted, appeal rights explained and copy of report given to Administrator.