Routine inspection·September 27, 2024

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Lourdes Cruz, Caregiver and explained the purpose of the visit. At 10:25am, Stacy Santam, Manager arrived and assisted LPA. Shortly after, Linda Morales, Administrator arrived and assisted LPA. The facility is licensed to care for six (6) elderly residents ages 60 and above, approved for (6) ambulatory of which (4) may be non ambulatory, of which (1) may be bedridden. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan. Bathrooms are maintained in operating condition. Operational Requirements: The Infection Control Plan was reviewed. However, the l icensee cannot provide a copy of the Plan of Operation and stated that the plan is not kept and maintained in the facility. Last Fire Drill was conducted on 09/10/2024 and training is conducted with staff on a monthly basis. Liability Insurance policy is valid and expires on 10/07/2024. Facility does not handle cash resources for the residents. Facility has working signal systems in exit points, which were tested and operational. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood. It consists of (5) resident bedrooms, (3) bathrooms, living room with screened fireplace, kitchen, dining area, laundry area, detached garage, and backyard. Currently, there are six (6) non ambulatory residents living in the facility. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector and 5 beds with 1/2 bedrail and (1) with full bed rail, linen, dresser, light, chair and sufficient closet space. Exit doors have auditory device. Backyard was inspected and has a shaded area and sitting area. Laundry area is located outside. There are no cameras in the home. LPA observed (2) fire extinguishers that were last serviced on 03/06/2024. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings in (2) bathrooms measured within the required 105 - 120 degrees Fahrenheit. However the hot water reading in bathroom #3 did not go higher than 84.9 deg F. *****REPORT CONTINUED ON LIC809-C***** Staffing: A total of nine (9) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, fingerprint clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 01/03/2025. Resident Rights-Information: Resident personal rights are posted. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Resident Records-Incident Reports: LPA reviewed (6) resident files. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including TB and Ambulatory Status), Appraisal and Needs Services plan and Resident Personal Rights observed. Some residents do not have I.D. and Emergency Information (Face sheet), Consent for Medical Treatment, Resident Personal Property and Physician's order for 1/2 bed rails on their files. Health Related Services: Medications were reviewed for (4) residents to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log and medication list to document medications given. Medications are administered as prescribed by the Physician. Incidental Medical Services: There is zero (0) resident with a restricted health condition. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable. Deficiencies cited. Exit interview and a copy of this report along with the appeal rights were provided to the Administrator/Licensee Linda Morales.