Routine inspection·October 31, 2023

On 10/31/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Staff, Saif Ali Choudry, who was informed of the purpose of the visit. LPA spoke with Administrator Sahar Choudry during the visit, At the time of the visit there was (1) staff and (5) resident present. The facility is a one story home with attached garage. No firearms or pools are present at the facility. The home has (4) bedrooms and (3) bathrooms. The residents served are elderly adults ages 60 years and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following: Infection Control: The LPA observed hand washing stations with hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan to train staff on infec tion control guidelines. Physical Plant: Physical plant was observed to be clean and in good repair. The indoor and outdoor areas were observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide were operational, and the hot water temperature was recorded at 106.5F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Record Review and Resident/Staff Files: LPA reviewed staff files and training. All staff have criminal clearance. During the visit the one (2) staff at the facility had CPR training which was expired.The administrator re-certification was verified as being submitted, however the Administrator and Assistant- administrator do not have documented training for review during the time of the visit. Deficiency was cited for staff records and plan of correction was created with administrator. Resident files were reviewed all of which posessed required documents. Health Related Services/ Incidental Medical Services: All client medication was locked in kitchen pantry. LPA reviewed resident medications, all of which were accounted for. One medication, M1 for Resident 1 (R1) did not have a current doctors order at the facility. The administrator was able to provide documentation by the end of the visit. A technical advisory note was documented for all resident medication records to be updated. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. Technical noted was documented for facility to update this to the current department requirements. The last fire drill was conducted April 2023. Deficiency was cited and administrator stated they would conduct Fire Drill by the end of the business day 10/31/23. An exit interview was conducted where a copy of this report along with deficiency, technical notes and appeal rights were reviewed and provided to Staff, Saif Ali Choudry.