Routine inspection·April 5, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Virginia Aguinaldo and explained the reason for the visit. The facility is a single story home located in a residential neighborhood and has (4) resident bedrooms, (2) bathrooms, a living room, a dining room, a kitchen equipped with a laundry area, a sun room, a detached garage, a covered front sitting area, and a back yard. Facility does not have large bodies of water. LPA Flores toured the facility with Virginia Aguinaldo and observed the following: Facility is in good repair indoor and outdoor. Living/dining/sun room have sufficient furniture that are in good repair. Kitchen was observed clean, sharps are locked in a drawer. Medication cups (prepared) were observed on top on counter top next to the refrigerator, hospice medication was observed in the freezer and a liquid medicine was observed in refrigerator door accessible to the residents and not properly stored. Sufficient food supplies were observed worth of at least 2 days of perishables and 7 days of non-perishables. Cleaning supplies were observed in cabinet inaccessible. Each resident room (4) was observed with sufficient lighting, furniture, and bedding supplies. Resident #2(R2) is in hospice and has full bed rails in bed. Bathrooms (2) were observed clean, and in working condition, a bottle of cleaning solution was observed in bathroom #1(B1) accessible to the residents. Water temperature was tested in each bathroom and tested between 106.8- 107.1 degrees F., which is within the required 105-120 degrees F. Front and back yard are clean and have a shaded seating area. LPA reviewed 4 residents medication and files. R2 does not have a bed rail request on file. Resident #3(R3) does not have a physician's report on file. Four residents are on hospice, facility has a hospice waiver for three only, facility is not operating within the license. LPA reviewed 5 staff files. Administrator certificate was observed for Ewa Nyczak #6020655746 exp: 9/22/24. Training was provided to staff. (CONTINUED ON LIC 809C) Infection Control plan, and Emergency Disaster plan (7/27/23) were reviewed. Let us Know PUB 475 poster was not observed posted at the facility. Exit interview was conducted with Virginia Anguinaldo and a copy of this report, LIC 809D, and appeal rights were provided.