Routine inspection·July 19, 2024

This facility is licensed to serve three (3) non-ambulatory and 3 (3) ambulatory residents over the age of 60. Bedroom#1 may retain two (2) non-ambulatory residents and bedroom#5 may retain one (1) non-ambulatory resident. This facility may retain no more than five (05) hospice residents. There are three (03) residents under hospice care. The facility is a single-story dwelling located in a residential neighborhood. Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection. LPA Ramirez met with Caregiver Jermin Pattiradjawane and explained the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected six (6) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets. LPA Ramirez observed the following deficiencies: Smell of urine omitting from resident bedroom #5, blinds missing and broken in resident bedroom#5, resident bedroom#5 screens were observed to have dust debris all over the screen, broken and discarded fridge in backyard, bubbling, peeling and yellow-brown on ceiling in living room area, and facility dryer was observed to be in disrepair. LPA Ramirez will issue Type B deficiencies. SEE 809-C. Food Service: LPA Ramirez did not observe sufficient supply of nonperishable for one week. LPA Ramirez counted between 10 to 20 cans of canned food. Seven (7) out of the twenty (20) canned good had best by dates of 2020, 2021, 2022, and 2023. LPA Ramirez observed two (2) out of the twenty (20) canned good to contain best by dates of July 11, 2024. LPA Ramirez observed five (5) unopened bags of chips with guaranteed fresh until dates of Jan 2024 and May 2024. LPA Ramirez observed one (1) half full tub of animal cracker cookies with a best by date of May 2024. LPA Ramirez observed one (1) unopen can of cookies with a best by date of June 7, 2024. LPA Ramirez observed two (2) unopened bags of popcorn with guaranteed fresh dates of Feb 2024. LPA Ramirez did observe perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Freezer was observed to have dead insects suck to bottom of freezer floor. Refrigerator floor contained dead insects and hair strands. LPA Ramirez observed several bags of sandwich bread to smell rancid and could smell it through the bag. Some bags of bread were open and per staff interviews, residents were being served this bread. 2 insect eggs fell out of a bag of bread that was semi open when LPA inspected the bread. LPA Ramirez will issue Type A & Type B deficiencies based these on observation. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D) in place. Present staff could not locate drills or recall drill being conducted in the last three months. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. Residents with Special Needs : No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Resident#1 (R1) did not have a current medical assessment on file. LPA Ramirez will issue Type B deficiency based on observation. See 809-C. Health Related Services/Incidental Medical Services: Medications are centrally stored in the kitchen cabinet and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. LPA Ramirez observed two (2) residents’ medications in the facility refrigerator to be accessible. LPA Ramirez will issue Type A deficiency based on observation. Staffing: Administrator Certificate for Yenny Indrawati and it expires 02/17/2025. 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 Ramirez observed required annual training, CPR and First Aid for two (2) out of the two (2) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for two (2) out of the two (2) personnel records reviewed. Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: This facility is licensed to serve three (3) non-ambulatory and 3 (3) ambulatory residents over the age of 60. Bedroom#1 may retain two (2) non-ambulatory residents and bedroom#5 may retain one (1) non-ambulatory resident. This facility may retain no more than five (05) hospice residents. There are three (03) residents under hospice care. Four (4) out of the six (6) residents are nonambulatory. The facility may only retain 3 nonambulatory residents. LPA Ramirez will issue Type A and Type B deficiency and an immediate civil penalty based on these observations. Resident Records/Incident Reports: LPA reviewed resident files for six (6) residents. Resident files are maintained at the facility. Eleven (11) deficiencies were cited today, six (6) civil penalty violations in the amount of $250 for each violation, for repeat offenses and one (1) immediate civil penalty for $500. Total amount of civil penalties and immediate civil penalties are $2,000. Exit interview was conducted and copy of this report, 809-D, LIC 421IM, LIC 421FC and appeals rights was provided.