Routine inspection·March 21, 2023

Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection using the CARE tools. LPA arrived unannounced and met with staff, Jae Maralit, who allowed entry. The purpose of the visit was explained. The facility is licensed for 6 non-ambulatory residents, ages 60 and over, of which 1 may be bedridden. The hospice waiver is approved for 3 residents. LPA toured the facility, reviewed records, and interviewed 2 staff and residents. The following were observed: Infection Control: The facility staff are aware of appropriate hand hygiene and when gloves should be worn. Facility has sufficient PPE supplies. LPA requested for the Infection Control Plan to be submitted by 3/28/23. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 6 residents residing at the facility which 2 are receiving hospice care and 2 home health services. The facility has the sufficient amount for liability insurance covering injury to residents and guests. Physical Plant & Environment Safety: The facility does not have any bodies of water or pool on site. There are 5 resident bedrooms, 1 live-in staff room with bathroom, 1 communal bathroom, living room, dining room, kitchen, and attached garage. Facility has operable smoke detectors and a carbon monoxide detector located in the dining area. Knives, cleaning solutions, and disinfectants are locked. There are no firearms or weapons stored at the facility. The hot water temperature in the bathroom was measured between the required range of 105-120 degrees F. Staffing : The administrator's (Jacklyn Concepcion) certificate expires on 7/21/24. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records-Training : Staff files are maintained at the facility. LPA reviewed the Administrator and 2 other staff files. LPA did not see sufficient annual training verification in their files. The CPR/First Aid certificates for all 3 personnel had expired. Resident Records-Incident Reports: Resident files are maintained at the facility and 4 out of the 5 files have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal, and Resident rights. Resident #5 is missing the current Physician's Report. Resident Rights-Information: The Local Ombudsman and Residents personal rights information are posted at the facility. However, LPA and staff did not observe the Licensing Complaint poster at the facility. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The foods are properly stored in the refrigerator. Incidental Medical & Dental: The medications are centrally stored and in their original containers. LPA reviewed 4 residents' medications and they are being administered as prescribed by the physician. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers. LPA requested for administrator to transfer information onto the updated LIC610E form. Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. There are currently 2 residents on hospice. Deficiencies are issued on the LIC809D. Technical advisory notes were also given. An exit interview was held with the Administrator via telephone. A copy of this report, LIC809D, appeal rights, and technical advisory notes were given to Staff Maralit.