Routine inspection·April 9, 2024

Licensing Program Analysts (LPAs) Cynthia Chan and Christian Gutierrez conducted the required annual inspection using the CARE tools. LPA arrived unannounced and met with staff, Maura Demapan, 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. LPAs toured the facility, reviewed records, and interviewed 2 staff and 2 residents. The following were observed: Infection Control: The facility staff are using gloves when needed to assist residents. Facility has sufficient PPE supplies. Staff receive Infection Control training annually. 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. There is one resident on hospice and 2 receiving 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 swimming pool on the premises. There are 5 resident bedrooms, 1 live-in staff room with bathroom, 1 communal bathroom, living room, dining room, kitchen, laundry area, 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. The hot water temperature 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. Personnel Records-Training : Staff files are maintained at the facility. LPA reviewed the Administrator and 2 other staff files. There were sufficient annual training on file. CPR & First Aid certificates are current for all 3 staff. Resident Records-Incident Reports: Resident files are maintained at the facility. LPAs reviewed all 6 resident files and they have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal, and Resident rights. Resident Rights-Information: The Local Ombudsman and Residents personal rights information are posted 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 in their original containers. LPAs reviewed 6 residents' medications and there are discrepancies found for 3 of the residents (Resident #2, #4, and #5). Some of the medications were not properly marked on the MAR log as given. Also, some of the medications did not appear to be given as prescribed, as the medications were still in the bubble pack. The start date noted on the bubble pack did not correspond to today's date. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and procedures. . Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. There are currently 1 resident on hospice. A deficiency was issued on the LIC809D. An exit interview was held with the Administrator via telephone. A copy of this report, LIC809D, and appeal rights were given to the staff.