Routine inspection·June 30, 2024

Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Caregiver Nicholas Loterena purpose of today’s visit. This facility is licensed to serve six (6) non-ambulatory of which one (1) may be bedridden. This facility may retain no more than six (6) hospice residents. There are four (4) residents under hospice care at this time. 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 five (5) 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 observe postings encouraging proper handwashing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. Food Service: LPA Ramirez observed sufficient supply of non-perishable for one week and 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). Planned Activities: Per facility staff, residents receive seated exercises during the week. Staff plays a video and leads residents in different exercises. 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 facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D) in place. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply and water supply. 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. Auditory devices and delay egress perimeters were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms 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. Staffing: Administrator Certificate for Luis Gabriel Santos expires 12/08/2025. 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 three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, and fingerprint clearance for two (2) out of the three (3) personnel records reviewed. Infection Control: There 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: The fire clearance is approved for six (6) non-ambulatory of which one (1) may be bedridden. This facility may retain no more than six (6) hospice residents. Resident Records/Incident Reports: LPA reviewed Resident files for six residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), and Preplacement Appraisal. No deficiencies were observed. Exit interview was conducted. A copy of this report was provided via email due to printer problems.