Routine inspection (multi-day)·June 15, 2024

Licensing Program Analyst (LPA) Kimberly Ramirez conducted subsequent annual inspection on 6/15/2024. LPA Ramirez was greeted by Rafael Constantini (Sales and Marketing Manager) and LPA explained purpose of today’s visit. Tanya Madrid (Director of Human Services) arrived within the hour to assist with inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Operational Requirements: The fire clearance is approved for (252) ambulatory residents and (108) non-ambulatory of which (18) may be bedridden. This facility may retain no more than (15) hospice residents. There are (11) residents under hospice care. LPA Ramirez reviewed facility liability insurance and auto registration for three (3) facility vehicles. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez and staff present during inspection were unable to gain access to staff files. LPA Ramirez observed required annual training only for eight (8) out of the ten (10) staff files requested. LPA Ramirez reviewed required annual training for staff working with dementia residents. LPA Ramirez was unable to review the following: CPR and First Aid, TB testing results, Health screening, fingerprint clearance, and job application. LPA Ramirez reviewed food handler certificates for kitchen staff. LPA Ramirez will issue Type B deficiency for not gaining access to staff files. Staffing: Administrator Certificate for Robert Barton (7033961740) expires 11/02/2025. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services. See 809-C for continuation. Resident Records/Incident Reports: LPA Ramirez reviewed Resident files for Resident #1 (R-1) through Resident #10 (R-10). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. One deficiency was observed during this inspection. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided.