Routine inspection·January 23, 2025

At 9:30am, Licensing Program Analyst (LPA) Huma Rahimi arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the staff. Vanisa Campbell, who granted access to the facility and Administrator Sylvia Jackson was contacted via phone. The Administrator arrived shortly after. LPA explained the reason for the visit. At 9:45am LPA conducted a tour of the physical plant and observed the following: Facility is licensed for capacity of six (6) non-ambulatory, of which one (1) may be bedridden (in room #1). Facility also has a hospice waiver for two (2) residents . Kitchen: At approximately, 9:45 AM 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 observed to be locked in a kitchen drawer. LPA observed that all cleaning supplies and laundry detergents are locked under the kitchen sink. LPA observed a fire extinguisher hanging on the kitchen wall and fully charged and purchased on 01/23/2025. Laundry is located by the kitchen and the washer and dryer were actively running and operational. Medications: At approximately, 9:50 AM LPA observed medications are centrally stored and locked in a kitchen cabinet. At 12:55 PM, during the medication review for Resident #1 (R1), LPA could not verify the accuracy of the medication administration due to the lack of incomplete Centrally Stored Medication Destruction Form. Administrator informed LPA that the Administrator did not complete the form and was unable to provide a reason. Continue on LIC 809C Bedrooms: LPA observed total of four (4) bedrooms designated for residents use. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has awake staff. Bathrooms: LPA observed two (2) bathrooms and both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and client's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. At 10:00 AM, hot water temperature measured at 113.7°F. Common Areas : The facility maintains a comfortable temperature at 76°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The facility does not have a garage. LPA observed two closets, one by bedroom #4 where the extra linen and towels were stored, and another one by the living room where PPE supplies were stored. Outside areas: At approximately, 10:10 AM LPA toured the outside area of the facility. LPAs observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Between 11:00am to 12:30pm, LPA reviewed records of five (5) residents and requested for one staff file. LPA was informed that Staff #1 (S1) file is not available for review since the Administrator did not complete a file yet. Resident files were not updated/completed. During the record review of the resident, LPA observed that Resident #4 (R4) was hospitalized twice. The first incident was on 12/09/2024, and the second incident was on 01/03/2025. LPA was informed that R4 was unresponsive on 12/09/2024 and was taken to the hospital. On 01/03/2025, R4 had a fall and R4’s lib was bleeding and R4 was taken to the hospital where R4 got stiches. LPA reviewed all incident reports on a system and did not observe any Incident Reports regarding R4. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO) since the Administrator did not know to submit an incident report to the department when such occurrences occur. Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. Smoke detectors/carbon monoxide . Smoke detectors and carbon monoxide monitors were tested at 12:35 PM, and observed to be functional. Continue on LIC 809C Administrative: LPA was not provided with a Certificate of Liability Insurance, LPA collected LIC500. Deficiencies were cited during today’s visit. Appeal rights explained. Exit interview conducted and copy of this report signed and delivered.