Routine inspection·September 17, 2024

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted at the facility by Sara Jane, House Manager. LPA met with Gideon Limpiado, Administrator via phone call and explained the purpose of the inspection. The facility is one-story building with five resident bedrooms, two resident bathrooms, living room, den, kitchen, dining room, laundry room, two caregiver rooms, attached 2-car garage and backyard. Facility appears clean, safe and sanitary. LPA observed the facility has the necessary postings posted on the walls. LPA noted residents were lounging in their rooms or the living room. All resident rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for residents in a a closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured between 105 and 120 degrees F. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was last serviced on March 16, 2024. Smoke/Carbon Monoxide detectors were tested and noted as operational. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen or garage. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a closet in the living room. The backyard has a shaded sitting/lounging areas. Exit gate is unlocked. LPA observed exit gate to be unobstructed. Based on record review, LPA observed facility staff present at the facility did not have current CPR certifications in their file. LPA observed facility does not have exception request for bed rails for two residents with bed rails longer than half. These residents are not on hospice. LPA observed facility does not have a physician's order for bed rails that are longer than half. Three citations are being issued. LPA issued Technical Violation advising facility to draft a dementia care plan and a hospice care plan. LPA reviewed three resident files and three staff files. LPA also reviewed medication for three residents. LPA interviewed one staff and one resident. Based on today's inspection, three deficiencies and two technical violations are being issued. An exit interview was conducted and a copy of this report and appeal rights were provided to the facility.