Follow-up·June 27, 2025

On 06/27/25 Licensing Program Analyst (LPA) Mario Leon conducted a case management, with primary focus on physical plant and medication management. LPA was met by staff two, Kathleen Mantes - Caregiver (S2), later by staff one, Cheresa Reyes - Caregiver (S1) and LPA explained the purpose of today’s visit. During today's tour, LPA observed three (3) staff present, for a ratio of 1:1.67 (one (1) staff to one point six-seven (1.67) resident(s)). The facility is licensed to operate for six (6), non-ambulatory, elderly adults ages 60 and above of which (1) may be bedridden, The facility is approved for six (6) hospice residents. Currently, the facility has five (5) residents in care. One (1) resident is currently receiving hospice services. The facility is a one-story house, located in a residential neighborhood, which consists of the following : four (4) resident bedrooms, two (2) staff bedrooms, two (2) bathrooms, a kitchen, a dining room, a living room, an activity room and an outside, tree-shaded, back yard and patio. LPA observed the facility to be fully furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and two-days of perishable and seven-days of non-perishable food was maintained adequately. An additional freezer is located in the back yard with additional frozen food items. Fire extinguishers are fully charged. The facility has last conducted emergency fire drill on 06/02/25. A review of the Medication Administration Record (MAR) of residents one (1) through five (5) (R1-R5) was observed and all entries have been entered correctly. From 10:00AM - 10:15AM LPA held an interview with resident five (R5). R5 has confirmed that staff are providing appropriate medication management. LPA observed First Aid Kit was maintained. A land-line phone was observed and tested, marked as operational. LPA observed smoke detectors in bedrooms and common areas, and a carbon monoxide detector located in the kitchen. LPA requested all detectors them to be tested and LPA verified all are in operational condition. The facility has current liability insurance on file, effective through 08/19/25. During the visit, LPA observed the facility's infection control practices and LPA observed screening protocols for visitors, staff,... Report continues, see LIC809-C. and residents, and sanitizing stations in common areas and restrooms and all mandated inspection control posters were posted. During today's tour, according to Title 22 regulations, LPA observed one (1) deficiency as follows: Screen, located in room #3, in disrepair. LPA also observed debris located in two (2) backyard exit doorsills and also in doorsill of room #3. Additionally, windowsills and screens have been observed as dirty, needing to be cleaned. Please see LIC809-D. An exit interview was held with staff one, Cheresa Reyes - Administrator designee (S1), and a copy of the facilities' appeal rights, deficiencies cited and this report have been provided.