Routine inspection·April 15, 2025

At approximately 10:15 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by facility Staff. Alma Fuentes, Administrator, was contacted via telephone and arrived within approximately five minutes. Facility is a Residential Care Facility for the Elderly (RCFE) with five (5) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for one (1), and is approved for six (6) residents. Facility does not currently have any Hospice residents in care. At approximately 10:45 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured slightly above the allowable range of 105 to 120 degrees F per Title 22 regulations. Administrator agrees to monitor the temperatures to operate within regulation. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were observed locked. However, LPA observed supplements in the medicine cabinet of an unlocked staff bathroom and an open bottle of wine in the facility refrigerator. Administrator had staff secure both immediately. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPA inspected three locked sheds in the backyard which contained care equipment, tools, and chemicals. LPA also observed two trailers on the premises which are currently being used for staff living quarters. Continued on LIC809-C... Continued from LIC809C... LPA observed residents in the common area and in their bedrooms. Administrator states staff engage residents in daily chair exercises, facilitate games time, coordinate musicians performing in the facility and more. Facility telephone was tested an operational during inspection. Facility's fire extinguisher was observed charged and was last serviced 10/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills, and the most recent drill was conducted 1/2025. LPA observed the facility's infection control plan and a supply of PPE. Facility has a generator for emergency preparedness. LPA reviewed facility's emergency disaster plan last updated 02/2025. LPA observed structural changes within the facility to resident bedroom number one (1) which now has an internal wall and door installed; resident living in a room cleared for staff, and two trailers currently being used for staff living quarters that are not accurately reflected on the facility sketch and are not on the current fire clearance as required per regulation. LPA informed Administrator that any required permits for the structural changes will need to be obtained, if applicable, prior to Administrator submitting a new facility sketch to Licensing requesting a new fire clearance. Administrator agrees to keep LPA informed on their progress. LPA reviewed five (5) resident files and five (5) staff files. Five (5) of five (5) staff files were observed missing proof of CPR and/or First Aid training from an approved American Red Cross provider as required per regulation. LPA observed no personnel records maintained at the facility for the Licensee who the Administrator states works at the facility occasionally and who performs staff in-service training sessions in her role as a registered nurse. Additionally, Staff 4 (S4) was missing proof of a health screening. Five (5) of five (5) resident files were reviewed and the file for Resident 5 (R5) observed with a wound on their right foot, contained a pre-appraisal from 2017 when the resident was admitted which states that the wound was a "stage II" wound. No orders, exceptions, care notes, or other required documents were observed. Further, based on file review, LPA discovered that Resident 2 (R2) has a suprapubic catheter. LPA did not observe an exception or any care notes related to this. LPA will return to the Department and conduct further file review and gather more information regarding the above residents. Continued on LIC809C... Continued from LIC809C... LPA observed four (4) of four (4) resident records missing a consent for emergency medical treatment at required per regulation as well as three (3) of five (5) residents files were observed missing physician's orders for a hospital bed with half rails as said beds were observed in use by all residents in the facility during today's inspection. LPA reviewed medications and medication logs which were observed stored and maintained within regulation. Facility does not manage P&I. Administrator stated they would like to apply for a change of ownership sometime this year under a new entity name and LLC. LPA will consult with Licensing Program Manager and determine whether an in office meeting is indicated. LPA will issues citation at a later date either in-office or will return to the facility to do so. No deficiencies were cited during today's inspection. Exit interview conducted with Administrator whose signature on form confirms receipt.