Routine inspection·December 3, 2024

On 12/03/2024 at 9:15 a.m. Licensing Program Analyst (LPA), Evelin Rios, conducted an unannounced Annual Required visit at the facility mentioned above. LPA was greeted by staff #1 (S1) who granted access. LPA observed appropriate postings on the entry and hallway wall. Staff #2 (S2) contacted the administrator. Administrator Designee , Stephanie Domingo met with LPA at the facility. LPA informed Stephanie of the purpose of the visit. At approximately, 9:20 a.m. a physical tour was conducted and LPA observed the following: Dinning area: LPA observed a large table with seating. Area was clean and clear of clutter. Dinning table and chairs appeared to be in good repair and sit the capacity of the facility. Bedrooms: LPA observed, six (6) resident bedrooms with sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. LPA observed over the counter medication on resident #4's (R4's) bedside table in bedroom #4. Stephanie removed it immediately. Review of R4's Physician's Report revealed they are not able to store own medications. LPA and Stephanie discussed the facility sketch and the approved fire inspection from 2019. LPA obtained a copy of current facility sketch with approved stamp from City of Lancaster Building and Safety for garage conversion. Administrator will submit an LIC 200 indicating caregiver bedroom from facility sketch in 2019 has been changed to resident bedroom #5. Bedroom #5 is currently vacant. Bathrooms: LPA observed three (3) bathrooms one (1) is located in a residents private bedroom. All bathrooms were clean and in good repair. Properly supplied with toilet paper, soap and paper towels. LPA observed appropriate grab bars, non-skid mats, and trash cans with fitted lids, to protect from cross contamination. (Continued on LIC809-C) (Continued from LIC809) The hot water temperature was taken from two (2) shared bathroom at approximately 10:26 a.m. and measured between 111.9°F and 114.3 120°F, within regulation.. Kitchen: LPA toured the kitchen area and observed S2 preparing breakfast for residents. LPA observed a 7 day non-perishable and 2 day perishable supply of food; properly stored. All knives and sharps were observed locked in a kitchen cabinet and inaccessible to residents. LPA observed a fire extinguisher fully charged with service date 11/14/2024. LPA observed four (4) telephones in the facility accessible to residents. Outdoor Area: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water. LPA observed a small shed used for storage. LPA also observed a vegetable garden. Living Room: LPA observed the living room to be clean and furniture appeared to be in good repair. A fire place was observed, secured with a screen. Smoke detectors were located throughout the facility, and were tested at 10:32 a.m., they were observed to be operational. LPA observed a carbon monoxide detector that appeared operational. Facility is also equipped with two fire doors and fire sprinklers. Laundry Room: LPA observed door to laundry room locked. Cleaning supplies such as chemicals and detergents are kept locked in the laundry room. Resident and Staff Files : Resident and staff files are maintained locked in a hallway walk-in closet. From 11:12 a.m. to 1:10 p.m., LPA conducted a file review of five (5) resident records to insure compliance of licensing forms and also conducted a file review of three (3) staff records to insure forms and training are up to date. Review of R4's admission agreement revealed, R4's representative and Licensee's representative signatures and dates were missing. Two (2) staff records did not have active 1st Aid and CPR certification on file. LPA reviewed liability insurance, infection control and LIC500. Medications : Medication and Medication Records are stored in a locked hallway walk-in closet. Medications were reviewed for proper storage and documentation at 2:12 p.m. Facility also uses a Medication Administration Record (MAR). Deficiency cited, refer to LIC809-D. Exit interview conducted. A copy of this report was provided. Appeal rights provided.