Routine inspection·July 26, 2023

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility to conduct the annual inspection year Required inspection of the facility. LPA met with administrator Emma Arutiunian and explained the reason for the visit. The LPA and the administrator conducted a tour of the physical plant at approximately 10:30 a.m. There are (6) bedrooms for residents and (1) bedroom for staff use only. Smoke alarms and carbon monoxide detector were not functioning at time of the visit. The administrator stated that the smoke and carbon monoxide alarm started emitting a sound at night and that could not be resolved by staff. The administrator contacted an alarm company to resolve the issue and stated that the company was going to resolve the issue same day of the visit later in the afternoon. The LPA observed all required postings in the entry area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Fire extinguisher was fully charged and purchased in May 23, 2023. KITCHEN: The kitchen appeared clean and the appliances and fixtures functional during the time of visit, sharp objects are stored in lock box that was kept on the kitchen counter. The LPA observed box to be locked at this time. Some cleaning supplies and disinfectants were observed stored inaccessible to residents under the sink. The LPA observed a sufficient amount of perishable and a seven-day supply of non-perishable food at the facility properly stored, however the facility lacked a water supply. The administrator stated that the water will be purchased by the end of the day and pictures of the water supply will be emailed to LPA by 07/27/2023. BEDROOMS: The residents’ bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate and clean bedding and linens such as sheets, pillowcases, and blankets. Continues on LIC 809C... BATHROOMS: The LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in the bathroom. Residents have sufficient amounts of supplies for personal hygiene properly stored inaccessible to residents. The hot water was measured in each bathroom during physical plant tour. Hot water measured within the required limit of 105-120 degrees Fahrenheit. COMMON AREAS: The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Laundry room is located right outside the hallway pass bedrooms #5 and #6. The LPA observed laundry room to be inaccessible to residents in care at this time. Cleaning supplies were stored in cabinets above washer and dryer. LPA observed cabinets to be locked at this time. There is an attached garage accessible from the outside and the laundry room. LPA observed garage to store an extra fridge and freezer for perishable foods. Extra medical supplies and furniture was also observed in the garage. SURROUNDING GROUNDS (Outdoors): Exit passageways were clear of hazards and obstructions. There was an area with proper furniture for outdoor use in the area located outside of living room to the left of the property, however the outdoor area lacked shade. The LPA informed the administrator that some form of shade (patio umbrella), must be provided for the comfort of residents and family members if they wish to meet outdoors. There are no bodies of water on the premises. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. 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 isolate residents in their private bedrooms. The facility’s policies and procedures as it pertains to infection control are adequate at this time. RECORDS: Records review began at 12:00p.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 1:12 p.m., medications are centrally stored and locked in a cabinet in the hallway; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications; however, the dates of bottles did not match the Centrally Store Medication and destruction record as of the time of the visit. An audit of two out of two medication bottles: Quetiapine (250mg, and 500mg) did not have the correct amount of tablets left in the bottles, as prescribed. Citations were issued. Exit interview conducted. Report issued and sent via email.