Routine inspection·April 8, 2025

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Escarling Godoy Manager and explained the reason for the visit. The facility is licensed to serve fifteen (15) non-ambulatory residents, ages 60 and above, and had six (6) Hospice Waiver approved. Facility is a single home located in a residential neighborhood. It consist of a lobby area, office, a kitchen, a family room, a dining room, 10 resident rooms, 5 resident bathrooms, 1 staff bathroom, a garage, a laundry area, a front porch, a back yard. LPA reviewed the following CARE inspection tool domains during this visit: Infection Control: Infection control plan was reviewed which meets current regulations. Hand sanitizer and proper sanitation was observed during the visit. There is a responsible person and emergency training was provided to staff. Personal protective equipment was observed. Operational Requirements: Facility maintains a plan of operation. Facility has a current liability insurance. Facility is operating within the license. Physical Plant/Environmental Safety: LPA conducted a tour of the facility with Escarling Godoy and observed the following: Facility was observed in good repair indoors and outdoors. All common areas are clean, and providing sufficient sitting area, and lighting. Kitchen area is clean, sharps were observed locked in a box. Medications were observed locked in the office. Cleaning supplies were observed inaccessible to residents in the garage. Laundry area was observed in good repair. LPA observed 5 random resident rooms, each in good repair, with all bedding supplies, and sufficient lighting. Five bathrooms were observed all in good repair, with grab bars, and non-slip shower floors. (CONTINUED ON LIC 809C) Water temperature was tested in the resident bathrooms between 115.5 - 127.5 degrees F., which is not within 105-120 degrees F. Carbon Monoxide/Smoke detectors were tested and are in working condition. Fire extinguishers were observed and last checked on 9/25/24. The backyard has a cover shaded area. Staffing: Administrator Clemencia Bousheri arrived at the facility shortly after. Staff have current CPR/First Aid training on file. Night staff have been provided emergency training. Sufficient staff were observed. Personnel Records/Staff Training: Administrator certificate was observed for Clemencia Bousheri #6004291740 exp. date: 4/5/25. Renewal documents have been submitted to the department. All staff records were available for review. LPA reviewed a total of 5 staff files which included medical assessment, TB clearance, background clearance, and initial and yearly training. Resident Rights/Information: Personal Rights, Let Us No poster (PUB 345), and Local Ombudsman posters were observed throughout the home. Planned Activities: Activity materials were observed. Outdoor area has a seating area and activity supplies to promote outdoor activities. Food Service: Sufficient food supplies were observed of perishables for at least 2 days and non-perishables for at least 7 days. There are residents with special diets, staff prepare meals accordingly. No pest was observed. Incidental Medical and Dental: There is an area designated to centrally stored medication in the office. Medications are label and in their original containers. LPA reviewed medication for 5 residents. Resident Records/Incident Reports: Residents records were available for review. LPA reviewed a total of 5 resident files which contained medical assessment, TB clearance, admission agreement, an appraisal, a needs and care plan. Disaster Preparedness: Emergency Disaster plan (LIC 610E 10/03) was last reviewed on 1/1/25 and an emergency disaster plan was reviewed. Last Emergency drill was conducted on 3/125 and they conduct monthly emergency drills. Residents with Special Health Needs: There are no residents with restricted health conditions under care. Facility is following dementia regulations. Medical assessments for residents with dementia were observed within the last 12 months. Auditory devices were observed in each exit door. Facility currently has three residents on hospice and keeps hospice plan on file. LPA interviewed 3 residents and 3 staff. Deficiency was noted per Title 22 Regulations. Exit interview was conducted with Administrator and a copy of this report was provided.