Routine inspection·August 26, 2024

On 8/26/2024, Licensing Program Analysts (LPA) Janette Romero and Debbie Palacios conducted an unannounced visit to the facility for a required annual inspection. LPAs met with Caregiver, Renato Galdones who was informed of the purpose of the visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents and an approved hospice waiver for four (4). LPAs were informed none of the residents at the facility are on hospice. During today's visit, there was six (6) residents and two (2) staff present. LPA Palacios toured the facility with Caregiver Galdones and observed the facility is made up of a one-story home with six (6) resident bedrooms, three (3) bathrooms, one (1) staff room, a kitchen, dining room, living room, and attached garage. During the tour, Caregiver Galdones tested three (3) of the smoke alarms/carbon monoxide detectors and LPA observed them to be operational. LPA also observed a charged fire extinguisher placed near the kitchen. Indoor and outdoor passageways were free of obstruction. The facility has outdoor shaded seating for the residents in care. There were no bodies of water observed on the premises. Medications are secured in a locked dining room cabinet. Resident bedrooms had the required furniture and lighting. Bathrooms had grab bars near the toilet and in the showers. LPA toured the kitchen and observed the facility had more than a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Resident files reviewed had signed admission agreements and residents with a dementia diagnosis had updated physician reports. Staff present have a criminal record clearance and valid first aid/CPR certification. During a record review, LPAs reviewed Resident 1's (R1's) Physician's Report's (LIC 602A's) dated 11/28/23 which indicates R1 is bedridden and unable to independently transfer themselves to and from bed. LPAs interviewed R1, who reported they are unable to reposition themselves or transfer themselves to and from bed. LPAs reviewed R1's Preplacement Appraisal Information LIC 603 dated 4/22/24 which indicates R1 is unable to move their arms and legs, and requires maximum assistance to move to and from bed. Interviews conducted reveled R1 is repositioned every two (2) hours. Based on the aforementioned, the facility is in violation of their approved fire clearance. An exit interview was conducted and this report was reviewed and provided to Caregiver Renato. along with a Confidential Names List (LIC 811), LIC809-D and LIC421M and appeal rights.