Routine inspection·December 29, 2022

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Caregiver Marlon Sambajon and explained the reason for the visit. LPA was later met by Administrator Toby Miclat. Physical Plant was toured, sample record of medications was reviewed, and food supply was inspected. The facility is licensed to serve six (6) non ambulatory residents over the age of 60 years old and a Hospice waiver for two (2) residents. The facility is located on a main street with an open yard. LPA observed the following: · Staff was not wearing a face mask when LPA was greeted at the door. Staff did not screen LPA until Caregiver Sambajon called Administrator Miclat and was prompted to screen LPA. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. · The facility consists of four (4) client bedrooms, living room, dining room, kitchen, TV room, laundry room, one (1) shared resident/staff bathroom, one (1) client bathroom, one (1) staff quarters, attached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the back patio. Passageways and exits are free of obstruction. · Shared resident/staff bathroom# 1 water temperature measured at 116.0 F which is within the required 105F - 120F degrees. Light was not working at the time of the visit. Toilet paper was not observed in shared/resident bathroom#1. Sink and bathtub in shared/resident bathroom#1 was dirty with soap residue and hair. Resident bathroom #2 water temperature was measured at 121.6F which is not within the required 105F-120 degrees. Light in resident bathroom#2 was not working during the visit. Paper towels and toilet paper were not present in resident bathroom#2. · No night-light was observed in hallway leading to resident bathroom#2. CONT ON 809-C Resident bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. Carbon monoxide detectors are located throughout the home. There is a fire extinguisher located in the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to residents. Cleaning supplies and toxins are locked in the laundry room and are inaccessible to residents. Required grab bars and skid mats were observed in the shower and near the toilet. · Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed. · (3) out of the (3) resident medications were reviewed. Medications are centrally stored in a cabinet located in the kitchen. · LPA reviewed four (4) staff files and discovered Staff1 (S1) Personnel file was missing a copy of Drivers License or birth certificate. LPA also discovered Staff 2 (S2) was not associated with the facility and staff has been actively working in the facility. · LPA did not observe enough PPE. Administrator Miclat requested additional PPE via email while LPA was conducting visit. · Fire drill was conducted on 05/19/22. Deficiencies cited, please see 809D for details. At the time of visit no other deficiencies were observed. Exit interview done with Administrator Toby Miclat and copy of report and appeal rights was provided.