Routine inspection·February 3, 2023

On 2/02/23, at 12:22 P.M., Licensing Program Analyst (LPA) Mario Leon conducted an unannounced required Annual visit with a primary focus on infection control. LPA was met by Evelyn Datu, Direct Support Professional (DS1) and Janice De Leon, Direct Support Professional (DS2), DS1 and LPA spoke with Gregg MacEllven, administrator (A1), who later arrived to the facility , via phone and the purpose of today’s visit was explained, The facility is licensed to serve 6 ambulatory elderly clients, of which all may be non-ambulatory . Ther e are currently (5) residents in the facility . All clients are currently ambulatory. The facility is a split-level structure located in a residential neighborhood. It consists of five (5) client bedrooms, one (1) staff room, two (2) full bathrooms, three (3) half-bathrooms, shaded back yard, front yard, laundry room and attached 2 car garage. LPA and DSP1 toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were clean and operational, yet outside of Title 22 regulations. The water temperature measured at 132.4 F in bathroom two (2). A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, as of 04/06/22, smoke detectors and Carbon Monoxide were operable. see LIC809-C During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (located in common areas and restrooms). LPA observed staff were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PINs) for any updates relating to COVID-19 guidance. During today’s visit there were five (5) deficiencies observed, see LIC809-D. Technical assistance notes were provided, see LIC9102. Exit interview held. A copy of the report, deficiencies, civil penalty, and appeal rights were provided to Gregg MacEllven, Direct Support Professional.