Routine inspection·April 1, 2025

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Lourdes Sandoval caregiver and explained the reason for the visit. Facility is licensed to serve 6 non-ambulatory residents over the age of 60, of which (6) may be bedridden, and has a hospice waiver for (6). The facility is a single home in a residential area and consist of a kitchen, a living/dining room, with 6 resident rooms, 2 bathrooms, a laundry area, a detached garage, a front yard, and a back yard. LPA reviewed the following CARE inspection tool domains during this visit: Infection Control: Infection control plan was reviewed which meets current regulations. Hand sanitizer and proper sanitation was observed during the visit. There is a responsible person and emergency training was provided to staff. Personal protective equipment was observed. Plan was last reviewed on 6/10/24. Operational Requirements: Facility maintains a plan of operation. Facility has a current liability insurance. Facility is operating within the license. Physical Plant/Environmental Safety: LPA conducted a tour of the facility with Lourdes Sandoval and observed the following: Facility was observed in good repair indoors and outdoors. Living room/dining room is clean, and providing sufficient seating area, and lighting. Kitchen area is clean and inaccessible to residents, sharps, medication, and cleaning supplies were observed locked in cabinets in the kitchen area. Six (6) resident rooms were observed clean with sufficient lighting, furniture, and bedding supplies. Full bed rails were observed in bedroom #2 and #3. (CONTINUED ON LIC 809C) Two (2) Bathrooms were observed clean in working condition with grab bars. Bathroom #2 was observed with no skid mat in the shower. Water temperature was tested between 111.5 - 112.5 degrees F., which is within the required 105-120 degrees F. Laundry room was observed in good repair. Activities were observed in a cabinet in the living room. Front yard and back yard have a shaded seating area. Garage is used to stored additional food supplies. There are no large bodies of water in the facility. Carbon Monoxide/Smoke detectors were observed, tested, and in working condition. Fire extinguishers were observed and last checked on 10/8/24. Ramps, exit doors, and passageways are free of debris and obstructions. Staffing: Designee staff Diana Castellano arrived at the facility shortly after. Staff have current CPR/First Aid training on file. Night staff have been provided emergency training. Sufficient staff were observed. Personnel Records/Staff Training: Administrator certificate was observed for Ani Karapetyan #6066778740 exp. date: 6/28/25. All staff records were available for review. LPA reviewed a total of 5 staff files which included medical assessment, TB clearance, background clearance, and training. Resident Rights/Information: Personal Rights, Let Us No poster (PUB 475), and Local Ombudsman posters were observed posted in the kitchen and living room. Planned Activities: Activity materials were observed. Per staff a contractor visits the home to provide music therapy and activities are provided daily by staff. Outdoor area has a seating area to promote outdoor activities. Food Service: Sufficient food supplies were observed of perishables for at least 2 days and non-perishables for at least 7 days. There are currently no residents on special diets. No pest was observed. Incidental Medical and Dental: There is an area designated to centrally stored medication in a cabinet with a lock in the kitchen. Medications are label and in their original containers. Staff have a log for PRN medications provided. Resident Records/Incident Reports: Residents records were available for review. LPA reviewed a total of 5 resident files which contained medical assessment, TB clearance, admission agreement, an appraisal, a needs and care plan, medication sheet. Disaster Preparedness: Emergency Disaster plan (LIC 610E 3/19) was last reviewed on 3/5/25. Last Emergency drill was conducted on 1/5/25. Record reviewed showed facility conducts quarterly drills. Residents with Special Health Needs: Postural support/bed rails were observed and physician's request were observed in residents files. (CONTINUED ON LIC 809C) However, two residents; resident #1(R2) was observed to have four half bed rails, two in each side of the bed and #3(R3) was observed to have full bed rails in the bed. R1 and R3 are currently not receiving hospice services. There are no residents with restricted health conditions under care. Facility is following dementia regulations. Medical assessments for residents with dementia were observed within the last 12 months. Auditory devices were observed in each exit door. Facility currently has one resident on hospice and keeps hospice plan on file. Deficiencies were noted per Title 22 Regulations and a technical violation was noted. Exit interview was conducted with Administrator and a copy of this report was provided.