Routine inspection·December 9, 2023

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 12/09/2023. LPA was met by Caregiver Jhonrev Jimenez 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). LPA OBSERVATIONS: The facility is a single-story dwelling located in a residential neighborhood and consist of three (3) resident bedrooms, one (1) staff bedroom, two (2) shared bathrooms, kitchen, dining room, living room, attached garage, front yard, and backyard. Front Yard: Front yard is well maintained, and no hazards were observed. Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed one (1) knife a top kitchen countertop, next to a cutting board and veggies, to be accessible to six (6) out of six (6) residents in care. Kitchen sink water temperature was measured at 124.3-degree F. LPA Ramirez observed chemicals and cleaning solutions, located in under kitchen cabinet, accessible to six (6) out of six (6) residents in care. Kitchen appliances were observed to be clean and in working order. LPA Ramirez observed lower kitchen cabinet located next to stove to contain several dead insects. Dining Room/Living room/: Dining room was observed to contain one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed nearby thermostat in this area to read 77 degree F. Linen Closet: Contained plenty linens, towels, and hygiene products. Resident Rooms 1-3: LPA Ramirez inspected three (3) shared resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens. LPA Ramirez observed auditory devices to be operable in all resident bedroom exits. Bathrooms 1-2: Water temperature in bathroom was within 105–120 degree F. LPA Ramirez observed grab bars and non-slip mats in shower and grab bars near toilet. LPA Ramirez observed chemicals and cleaning solutions, located in under bathroom#1 sink cabinet, to accessible to six (6) out of six (6) residents in care. Backyard: No hazards were observed. Plenty of shade and seating was observed. Emergency Drills: Last documented fire drill was conducted on 11/12/23 at 2:15 pm Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: 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 five (5) personnel records. Documented proof of required annual initial dementia training required within the first 4 weeks of employment was not observed for four (4) out of the five (5) personnel records reviewed. Staff#3 (S3) did not have documented proof of criminal clearance of criminal exemption. Administrator Certificate was observed for Janice Jabonero with an expiration date of 03/23/2024. Resident Files: Six (6) resident files were reviewed. LPA did not observe required physician’s report for R6. LPA Ramirez did not observe required annual physician’s report for R2. Liability Insurance & Infection Control Plan: LPA Ramirez obtained a copy of liability insurance during visit. LPA Ramirez observed updated infection control plan. Deficiencies and technical advisories are being cited. A copy of this report, 809-D, LIC 9120 and appeals rights was provided.