Routine inspection·June 2, 2023

Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with Staff Maria Angelica Ocampo DSP who allowed entry. Administrator Teodora Manohan was contacted via mobile phone and LAP discussed purpose for the visit. Administrator gave Maria authority to assist with visit. The facility is licensed for 6 residents ages 60 and over. The fire clearance is approved for six ambulatory residents of which 4 may be non-ambulatory. There is a hospice waiver approved for 1 resident. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies but did not have an Infection Control Plan at the facility during the visit. Operational Requirements: The facility has plan to accept or retain clients with dementia. There are currently 0 bedridden residents and 4 non ambulatory resident residing at the facility. The facility did not have proof of enough liability insurance covering injury to residents and guest. Physical Plant & Environment Safety: There are 4 resident bedrooms, 1 bedroom is shared. ! staff room with a bathroom 1 bathroom, living room, dining room, kitchen, and an attached garage. Facility has operable smoke and carbon monoxide detectors located in each room and hallway. Knives, cleaning solutions, and disinfectants are locked in the cabinets. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms and kitchen sink. The hot water temperature in the bathroom and kitchen were measured between 111.7 – 113.1 degrees F which is between the required range of 105-120 degrees. Staffing : There appears to be sufficient staffing at the facility. The administrator’s Teodora Manohan certificate expires 12/25/2023. Staff employed are all over the age of 18. Personnel Records-Training : Staff files are maintained at the facility. Staff have current CPR/first aid training and no evidence of on-going training, Documents for staff indicate last training was in 2013. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. However, they were not up to date. Resident Rights-Information: The Complaint poster is posted by the main entry. Visiting hours are posted. Resident rights were not posted during time of visit. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are not sufficient supplies and equipment to meet resident's physical capability. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator to avoid cross contamination. Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA review medications for 4 residents. LPA did not observe PRN authorization letters for 4 residents during visit. LPA observed some medications stored in refrigerator and accessible to residents. Medication is being administered according to doctor’s orders. Disaster Preparedness: The facility does not have a current Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff did not received training on appropriately caring for residents with dementia, those on hospice, and receiving oxygen. No Smoking - Oxygen in use signs are not posted on the doors of residents using oxygen. During the visit today, LPA observed deficiencies and are indicated on the LIC809D. Deficiency sited (See 809D) An exit interview was held. A copy of this report, LIC809D, and appeal rights were given to Staff Maria A. Ocampo.