Routine inspection·July 14, 2023

Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with Administrator Toni Santos and LPA explained the purpose of the visit. The facility has a capacity of 6 residents. It is licensed to serve elderly residents age 60 and above, approved for 6 non-ambulatory residents. Facility is approved for 6 hospice waivers. One bedridden. The facility cares for elderly residents with dementia. Administrator certificate is current and expires on 02/12/2024 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, mask and gloves while assisting residents with 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. Operational Requirements: The facility has plan to accept or retain clients with dementia. The facility has proof on file of enough liability insurance covering injury to residents and guest. Physical Plant & Environment Safety: The facility is in a residential neighborhood and consisted of 5 resident’s bedrooms, 2 bathrooms, living room, kitchen, dining room, activity room, medication room, and activity area in the patio with shade. Facility has fire alarms/carbon monoxide detectors and were tested during visit. Knives are inaccessible to clients. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms sinks. The hot water temperature measured 105.8 degrees F which is between the required range of 105-120 degrees. Staffing : There appears to be sufficient staffing at the facility. Staff employed are all over the age of 18. Personnel Records-Training : Staff files are maintained at the facility. All staff have current CPR/first aid training and evidence of on-going training. (Continued on 809C) Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-Admission Current Appraisal are missing on all residents. Resident Rights-Information: The Complaint poster, Residents personal rights and LET US KNOW 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 is properly stored in the refrigerator to avoid cross contamination. Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed all 6 residents' medication files and medication is being administered according to doctor’s orders. PRN medications are missing PRN authorization letters and labels or some residents. Disaster Preparedness: The facility has 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. Facility did not notify department of accepting hospice resident. No Smoking - Oxygen in use signs are posted on the doors of residents using oxygen. Facility accepted resident with stage 3 pressure sore. Deficiencies cited (See 809D) and 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 Administrator Toni Santos.