Routine inspection·October 12, 2024

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit on 10/12/24 and was greeted by Caregiver Mildred Luwalhati. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single-story dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be accessible to residents in common bathroom #1. S2 removed disinfecting liquid after LPA Ramirez notified staff of violation. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in kitchen cabinets. See 809-C Residents with Special Needs : Pool with fenced gate and latch was observed in backyard. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. LPA Ramirez did not observe notification in R1, R2 or R3's resident record, from the licensee, that notified the Department in writing within five (5) working days of the initiation of hospice care services. Licensee has hospice waiver approved for two (2) residents only. R1, R2 and R3 are currently on hospice care. LPA Ramirez did not observe statement signed by R3 or R4's roommate, indicating his or her acknowledgement that their roommate (R2 & R3) intend to receive hospice care in the facility and their agreement to voluntary grant access to the shared living space to hospice caregivers, and the resident's support network of family members, friends, clergy and others. Health Related Services/Incidental Medical Services: The medications are centrally stored and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. Staffing: Administrator Sinclair’s personnel record was not made available during inspection. LPA Ramirez could not verify Administrator Sinclair’s administrator certificate. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. During inspection, LPA Ramirez observed S2 providing care and supervision to residents. LPA Ramirez requested S2’s personnel file, however, S2 revealed today was their first day working at the facility. Per back- up Administrator Michelle Aguirre, S2 is fingerprint cleared, however, S2 is only covering for another caregiver that called out ill. Administrator Michelle Aguirre revealed to LPA Ramirez that she received S2’s criminal clearance prior to S2 working at the facility. LPA Ramirez was able to verify S2 is criminally cleared through an internal process. LPA Ramirez did not observe criminal clearance, medical clearance, job application, CPR/First Aid or initial training for S2 during record review. Personnel Records Training: Not all staff files are maintained at the facility and made accessible to LPA Ramirez during inspection. LPA Ramirez observed CPR and First Aid for one (1) out of the one (1) personnel record reviewed. LPA Ramirez did not observe TB testing results, Health screening, and job application for S1. During personnel record review, LPA Ramirez observed S1's documentation of training record to be blank. Infection Control: Staff is 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. Operational Requirements: The fire clearance is approved for six (6) non-ambulatory of which one (1) may be bedridden and reside in bedroom#3. This facility may retain no more than two (2) hospice residents. There are three (3) residents under hospice care during inspection. LPA Ramirez did not observe liability insurance for the facility during record review. Resident Records/Incident Reports: LPA reviewed resident files for six (6) residents in care. 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. During resident records review, R4 & R5 did not have medical assessment in their file. Six (6) violations were observed and cited during annual inspection. Exit interview conducted. A copy of this report, 809-D and appeals rights was provided via email.