Routine inspection·October 17, 2023

On 10/17/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Staff, Lorena Guillen, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (3) residents present. The facility is a one story home with (5) bedrooms and (3) bathrooms and attached garage. No pools or firearms are at the facility. The residents served are elderly ages 60 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 and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan to train and follow infection 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 was operational, and the hot water temperature was recorded at 105F. LPA observed cameras in the facility common area and spoke with the licensee who stated they did not have consent forms for the residents. Deficiency will be cited for this. A plan of correction was created with the licensee to update their plan of operation and admission agreement to reflect this. 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 did not met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Plan of correction was made with the staff and licensee. Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. The listed administrator has a current administrator's certificate. Two (2) resident files were reviewed, and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All client medication was locked in kitchen pantry. LPA reviewed resident medications, and found Resident #1 (R1)'s PRN medication for pain was not filled at the facility. LPA was informed by staff that they primary c are provider would be coming the next day to fill the medication as it had previously expired. Deficency was cited and plan was correction was created with licensee. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The last fire drill was conducted 9/23/23. LPA observed emergency exits and emergency supplies. An exit interview was conducted where a copy of this report along with LIC809-D page, and appeal rights were reviewed and provided to staff, Lorena Guillen.