Routine inspection·August 13, 2021

Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with the stafffrom Kitchen- Eufrosino De Casa and explained the reason for the visit. Shortly after, the administrator Evangeline De Casa arrived and assisted with the visit LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and approved on 7/26/2021. The facility consists of (10) resident bedrooms and (8) bathrooms on address 10337 and (4) residents bedrooms and (2) bathrooms on address 10329 (2) , dining area, living room/TV area , outdoor activity areas,smoking area and garage w/ laundry area. LPA toured the entire facility and observed 6 out of the 14 bedrooms including room#3, #4, #5, #6, #7 and #8. All bathrooms were clean with required grab bar and nonskid mats in place. LPA observed bathroom#4, #5, #6 on address 10037 and bathroom#1 on address 10329,some of the light bulbs are missing and the overhead lighting was missing too. In addition, LPA also observed flies were flying around in all bathrooms. Hot water was tested and noted between 115.5 and 117.8 degrees.All rooms checked mattresses and bedsprings are in good repair, adequate lighting and closet space observed. LPA also observed perishable and non-perishables food supply was adequate at time of visit. Outside grounds were toured. Backyard was free of debris, exit ways and pathways were clear of hazards. LPA's reviewed 5 resident files to confirm emergency contact is updated. LPA also reviewed 3 staff files to confirm health screenings and fingerprint clearances. LPA's reviewed 5 residents' medications. Resident #1(R1's) Acetminophen 500mg and Resident #2 (R2's) Benztropine Mesylate 1mg and Metformin HCL and Resident#3 (R3) Gabapentin 300mg and Resident#5 (R5's) Olanzapine 20mg were not present at the facility. Administrator indicated the medications had run out and hasn't delivered yet The deficiencies cited are documented on the attached 809D. A copy of the report and appeal rights will be provided to administrator Evangeline De Casa. Due to some technical difficulties and LPA was not able to print the documents during the required inspection and LPA emailed the documents to administrator Evangeline De Casa.