Routine inspection·March 6, 2023

Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA arrived unannounced and met with Staff, Kamaria Noor, who allowed entry. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. The fire clearance is approved for (5) non-ambulatory residents in rooms #1, 2, 4, and 5. Bedroom #3 is approved for (1) bedridden. There is a hospice waiver approved for 6 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 5 non-ambulatory residents residing at the facility. Bedroom #3 is the designated room for (1) bedridden resident only. The facility has the sufficient amount for liability insurance covering injury to residents and guest. Physical Plant & Environment Safety: There are no pool or bodies of water at the premises. There are 5 bedrooms, 2 bathrooms, living room, dining room, kitchen, and an attached garage. The garage has an additional room allotted for a live-in staff room. Facility has operable smoke and carbon monoxide combo detectors located in each room and hallway. Knives, cleaning solutions, and disinfectants are locked in the cabinets. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms and kitchen sink. The hot water temperature in the bathrooms were measured between 126 -129 degrees F which are above the required range of 105-120 degrees. Staffing : There appears to be sufficient staffing at the facility. The administrator's (Thang Duong) certificate expires on 06/02/23. Staff employed are all over the age of 18. Personnel Records-Training : Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator to avoid cross contamination. Incidental Medical & Dental: The medications are centrally stored and in their original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. During the visit today, LPA reviewed all 5 residents' medication and did not observe the MAR to be completely filled out according to the date administered. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff received training on appropriately caring for residents with dementia, those on hospice, and receiving oxygen. No Smoking - Oxygen in use signs are posted on the doors of residents using oxygen. During the visit today, LPA observed some deficiencies and are indicated on the LIC809D. Technical advisories were also provided. An exit interview was held. A copy of this report, LIC809D, technical advisory notes, and appeal rights were given to Co-Administrator Elizah Arganosa.