Routine inspection·January 28, 2025

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Marissa Carreon and explained the reason for the visit. The facility is licensed to serve 5 non-ambulatory and 1 bedridden residents over the age of 60, with an approved hospice waiver for 6. The facility has 5 bedrooms, 3 bathrooms, a living room, a dining room, a TV room, a kitchen and an attached garage. The outdoor facility has a front yard, and back patio. LPA toured the facility with Marissa Carreon and observed the following: All common areas: Living room, dining room, and TV area are clean with furniture in good repair. Fireplace located in the living room is covered. A/C vent in TV area's ceiling is full of dust mites. Required posters were observed in the living room. Each resident rooms (5) have sufficient lighting, the required furniture, lighting, and bedding supplies. Room #1 has a piece of frame wood coming off on the exit door to the patio. Room # 2's bed was observed with full bed rails, resident is no longer in hospice. Room #5 has a dresser that has 3 broken drawers. Three (3) bathrooms were observed each is in working condition, showers have grab bars and skid mats. Water temperature was tested between 105.0-106.8 degrees F., which is within the required 105-120 degrees F. Kitchen was observed clean. Sharps were observed locked in a drawer. Medication cabinet was observed locked. Sufficient food supplies were observed. Cleaning supplies were observed in the garage. Garage is used as storage. Smoke/ Carbon Monoxide detectors were observed and tested. Fire extinguisher was observed mounted in the kitchen and last checked on 12/30/24. Facility has auditory devices in each door as they serve dementia residents. Sound device in front door, exit door to garage, room #1, and room #4 were not on during the visit. Backyard, passageways, and front yard are free of debris and have shaded seating area. Main entrance exit door was observed with a lock that requires a key from both sides inside and outside. Facility has one item to promote activities, or activity schedule was observed. LPA reviewed medication for 3 residents, and files for 4 residents. Resident #2(R2) has PRN medication prescribed that has been log provided each day for the month of January. (CONTiNUED ON LIC 809C) However, The date and time the PRN medication was taken, the dosage taken, and the resident's response are not documented. R2 was found not to be on hospice and a full bed rail was observed in their bed. R2's admission agreement was missing signature. No hospice initiation or discontinuation were observed or submitted to the department for R2 and R3. LPA reviewed 3 staff files. Staff #3(S3) was cleared and associated to the facility on 3/1/24 and has only 24 hours of initial training. LPA reviewed LIC 500 - Personnel Record and it list 3 staff schedule to work Saturday- Sunday between 6am-6pm. No additional staff files for review, no night staff was listed, and LPA observed both staff working the morning shift. LPA reviewed Infection control plan and emergency disaster plan. Per disaster drill log, drills were conducted on 7/6/24 and 12/1/24. LPA interviewed 3 resident and 2 staff. Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.