Routine inspection·June 4, 2024

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Required 1-year Visit on 06/04/2024. LPA was met by Caregiver Bobbie Robertson and explained the purpose of the visit. The facility is licensed to serve six (6) residents over the age of 60, of which six (6) may be non-ambulatory and has a hospice waiver approved for four (4). There are currently two (2) residents receiving hospice care at this facility. Video surveillance was observed in common areas. LPA OBSERVATIONS: The facility is a single-story dwelling located on a residential street and consists of four (4) resident bedrooms, three (3) bathroom, kitchen, dining room, living room, attached garage, front yard, and backyard. LPA Ramirez observed auditory devices on entry of door to be operational, sliding door and exits. Front Yard: Was clean and well maintained. No hazards were observed. Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located under kitchen sink, to be inaccessible to six (1) out of one (1) resident in care. Kitchen sink water temperature was measured at 116.5 degrees F. Kitchen appliances were observed to be clean and in working order. Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. Nearby thermostat was observed to read 71-degree F. Linen Closet: Contained plenty linens, towels, and hygiene products. SEE 809-C Resident Rooms 1-4: LPA Ramirez inspected four (4) resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens. Bathrooms 1-3: Water temperature in all bathrooms were measured to be within 105- 120 degrees F. Backyard: Was clean and well maintained. No hazards were observed. Plenty of shade and seating was observed. Garage: PA Ramirez observed emergency water and extra PPE/linens, and toiletry items in this area. Access to garage was observed to be inaccessible to six (6) out of six (6) residents in care. Emergency Drills/Emergency Disaster Plan/First Aid Kit: LPA Ramirez observed Emergency & Disaster Plan (LIC 610E) during inspection. Last fire drill was conducted on 03/24/24. Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable. Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for two (2) staff. LPA Ramirez observed an expired Administrator’s certificate for Stark Pleitez, Ana with an expiration date of 05/25/2021. LPA Ramirez will issue Type B deficiency based on this observation. LPA Ramirez observed required annual training, CPR and First Aid for two (2) out of the two (2) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for two (2) out of the two (2) personnel records reviewed. Resident Records: Five (5) out of the six (6) resident records were accessible to LPA Ramirez. R1 and R2 were observed to missing required annual medical assessment. LPA Ramirez will issue two (2) Type B deficiencies based on this record review and observation. Liability Insurance & Infection Control Plan: Facility will send proof of liability insurance within 7 calendar days. Facility will infection control plan within 7 calendar days. Exit interview was conducted. Three (3) deficiencies were cited during this inspection. A copy of this report, 809-D and appeals rights was provided.