Routine inspection·March 11, 2024

On 03/11/2024 at 08:35 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with Staff #3 (S3) and was granted entry to the facility. At the time of the visit there were two (2) staff present, and six (6) residents present. Administrator Gabriel Torres -Thompson was contacted and informed of the visit. Facility Director Joaquin Thompson arrived during the visit. LPA Brown explained the purpose of the visit to Facility Director Joaquin Thompson. The facility is a five (5) bedroom, four (4) bathroom home with a kitchen/dining area, living room, laundry room and detached garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which four (4) can be ambulatory and two (2) non-ambulatory residents and one (1) may be bedridden resident. The facility has one (1) Hospice Waiver. The current census is six (6) residents. LPA Brown was accompanied by Staff #3 (S3) to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor passageways but observed obstruction to outdoor passageways/area. LPA Brown observed glass window in the the backyard and a fire pit not used, metal chairs and metal table in disrepair. Deficiency will be issued. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. However, LPA Brown observed insufficient lightning in Room #1 and S3 reported to LPA Brown that the light in Room #1’s not working and need to be replaced. Deficiency will be issued. Also, LPA Brown observed 2nd floor loft being utilized as bedrooms, three (3) beds observed and one (1) large sectional also being utilized as a bed. Deficiency will be issued. . ***Continuation in LIC809C *** Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms. Also, LPA Brown observed Resident #3 (R3) and Resident #5 (R5) with half bed rails Facility Director Thompson reported to LPA Brown that R3 and R5 does not have written order from the physician indicating the need for half bed rail for mobility. Deficiencies will be issued. LPA Brown measured and observed the water temperatures in the bathroom to be at 106 degrees F. The facility is equipped with operating smoke detectors, carbon monoxide alarms and charged two (2) Fire Extinguisher. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster and the disaster plan were posted in a common area. In addition, during the tour of the facility, LPA Brown observed two (2) big gallons of paint in the backyard of the facility, not locked and accessible to residents in care. Deficiency will be issued. There was a designated storage space for resident/staff files. Also, there is a designated area for the resident’s medications that's locked. Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility. Care & Supervision: The facility has an administrator and a facility director present in the facility. LPA Brown observed sufficient number of staff to provide care and supervision to the residents in care except for night (NOC) shift. Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and care plans. LPA Brown observed no Pre-placement appraisal completed by the Licensee as required for Resident #2 (R2), Resident #3 (R3) and Resident #6 (R6) in their facility file. Deficiency will be issued. Also, LPA Brown observed Resident #3 (R3) not having an updated Physician Report, physician signature date is 07/26/2022 and per records review, R3 has dementia. Deficiency will be issued. LPA Brown reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis test result. LPA Brown observed that the files were complete. However, during the visit on 03/11/2024, LPA Brown interviewed Staff #3 (S3) and S3 reported to LPA Brown that S3's administering R3 glucose testing for R3. Deficiency will be issued. ***Continuation in LIC809C *** LPA Brown explained that S3 should assist R3 on glucose testing using "hand over hand" but not to do it for R3. S3 verbalized understanding. In addition, LPA Brown observed no staff scheduled to work on a night shift (NOC) shift. Staff #3 (S3) reported to LPA Brown that S3 sleeps when the resident sleeps at night and confirmed no staff are scheduled to work at night, awake and working at night. Deficiency will be issued. An exit interview was conducted where this report (LIC809), LIC809D, LIC9102 TA and Appeal Rights were discussed and provided to staff Sandra Hernandez.