Routine inspection·March 5, 2025

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Required 1-Year annual evaluation using the Care Inspection Tool. LPA was greeted and granted entry by Caregiver Azalia Ayala and explained the reason for the visit. Administrator (Admin) Lourdes Rivero arrived on premise to assist with the inspection. Administrator Rivero has a valid administrator's certificate expiring on July 30, 2026. The facility is a single story structure and is licensed to operate for six non-ambulatory residents and has a hospice waiver for two residents. Based on observation, there are two staff on duty caring for six residents of which three are in hospice care. It is determined that facility is operating beyond the conditions and limitations specified on the license by exceeding the number of hospice residents that can be accepted at one time. During the walk through, LPA observed four resident bedrooms and two and a half resident bathrooms. Resident bedrooms had all required furnishings. LPA observed the following issues in the bedrooms: Resident #5 (R5) did not have a bed rail order and the window screen in the bedroom of Resident #4 (R4) has a tear that needs to be repaired. Bathrooms were found to be in compliance, clean, and operational. The hot water temperature measured at 109.4, 107.0, and 107.7 degrees Fahrenheit. All common areas were inspected including the attached two car garage. LPA observed sufficient emergency food and water in the garage. LPA did not observe a generator and/or emergency lights as indicated on the Emergency Disaster Plan (LIC 610D). Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available in the kitchen and garage. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. Both exit gates were self-closing and self-latching. LPA observed sufficient seating and shading. The fire extinguisher was charged, mounted, and serviced on April 22, 2024. The auditory devices dual functioning smoke/carbon monoxide detectors were tested and operational. The auditory device in the master bedroom sliding door was not operable. Emergency evacuation drills are conducted quarterly. Last known drill was conducted on February 23, 2025 at 2:00pm per review of the log. The first aid kit contains all necessary elements. The facility land line number, (949) 716-4497, was tested and remains available. The liability insurance is valid expiring on March 12, 2025. Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the incorrect size of 8.5"x11." LPA conducted a file review of all residents and two staff. Discrepancies noted with staff files. Two out of the two staff did not posses a CPR/First Aid Training certificate. Medications were audited. No concerns. Interviews were conducted. The following items were addressed during the exit interview: to post the license and Complaint Poster (PUB 475) in the correct size, to repair the window screen tear in R4's bedroom, replace the battery for the auditory device on the sliding door of the master bedroom, cover the exposed wire in the ceiling of the hallway, amend the LIC610D as well as complete page 9, conduct quarterly drills of various emergency scenarios per shift, obtain a full bed rail order for R5, ensure at least one staff on duty per shift possesses a CPR/First aid certificate, to submit a hospice waiver to the Department requesting an increase in hospice as the facility is currently approved to accept two hospice residents, and to pay the annual dues due on March 30, 2025. Based on the observations made during today's visit, deficiencies are being cited. Advisory Notes (LIC9102s) are also being issued. An exit interview was conducted with Administrator Lourdes Rivero, and a copy of this report (LIC809/LIC809-C), LIC809-Ds, LIC9102s, LIC811s, appeal rights, and a copy of the regulation Hospice Care Waiver 87632 were provided at the end of the visit.