Routine inspection·December 9, 2024

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 12/9/24. LPA arrived unannounced and met with Staff. The backup administrator, Denise Molde, arrived shortly to assist with the visit. The facility is licensed to served 6 residents, ages 60 and over, of which 4 may be non-ambulatory. There is an approved hospice waiver for 4 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tools. The following were observed: Infection Control: Facility has an Infection Control plan and are continuing to clean and disinfect the home. They are using appropriate hand hygiene and wearing gloves while assisting residents. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are no residents utilizing oxygen at this time. Facility has the required amount of liability insurance coverage. Physical Plant & Environment Safety: The facility consists of 5 resident rooms, 2.5 bathrooms, living room, dining room, kitchen, laundry room, and attached garage. The hot water temperature was measured over the required range of 105-120 degrees F. There are no swimming pool or bodies of water on the premises. The fireplace is adequately screened. There are smoke and carbon monoxide combo detectors located throughout the home. LPA observed knives stored in the dishwasher and not locked. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator. Staffing : The facility has sufficient staffing to meet the needs of the residents. All staff members have current CPR & First Aid certificates. Personnel Records-Training : LPA reviewed 3 Staff files. The administrator's (Riza In) certificate expires on 6/26/24 but verified the renewal has been submitted prior to expiration. Staff have fingerprint clearance and associated to the facility. Staff files have the required documents such as personnel record, health screening with TB results, and dementia care training. Resident Records-Incident Reports: LPA reviewed 5 resident files. The files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, appraisal/needs and service plan, and personal rights form. Resident Rights-Information : Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff. Planned Activities : Facility has sufficient space to provide indoor and outdoor activities to accommodate residents. Incidental Medical and Dental : LPA reviewed medications for all 5 residents and there were no discrepancies found. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Emergency procedures are indicated on the form. Disaster drills are conducted quarterly. Residents with Special Health Needs : Facility accepts and retains residents with dementia. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence. There are currently no residents with a prohibited or restricted health condition. Deficiencies are issued on the LIC809D. An exit interview was held. A copy of this report along with appeal rights was given to D. Molde.