Routine inspection·July 28, 2023

On 7/28/2023, at 11:30 a.m., Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Barinder Kaur who was informed of the purpose of visit. Administrator Hemalata Bansode arrived during the visit. The facility is approved for three (3) ambulatory and three (3) non-ambulatory residents, of which one may be bedridden. Facility has a hospice waiver for three (3) residents. During the visit, there was four (4) residents and (1) staff present. LPA toured the facility’s interior and exterior with Caregiver Kaur, and observed the following: Kitchen: LPA observed kitchen to be clean. Food is stored in a safe and healthful manner. LPA observed the facility had sufficient perishable and non-perishable food items. Knives/sharps are secured in a locked kitchen cabinet. Dining and Living room: LPA observed area to be clean and furniture in good condition. LPA observed a resident resting in the living room and the other residents sleeping in their rooms. Hallway : LPA observed hallway to be clean with no pathway obstruction. Carbon monoxide & smoke detectors were tested and functioning properly. Fire extinguisher is charged and mounted on entrance hallway. Bedrooms : Resident bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting. During tour of Resident #1's bedroom, LPA observed R1's mattress was soiled/stained. Deficiency cited. Continued on LIC809-C.. Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a cabinet near the kitchen. LPA reviewed physical medications and Medication Administration Record (MAR) for R1 and discovered there were no notations on R1's MAR for several dates in July 2023. LPA also observed that the medication hour column in R1's MAR had some corrections made with a White-Out pen/brush. Administrator Bansode stated that R1 was at the facility on the dates in question and added that facility staff dispensed medication for R1 and must have forgotten to initial the MAR. Administrator Bansode stated that facility staff noted the wrong time in the medication hour column and used white-out to correct it. Deficiency cited. Bathrooms: Bathrooms have a working toilet, wash basin, and were equipped with a grab bar in the shower. The hot water temperature measured at 107- and 108-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the residents in care. Records: Staff #1 (S1) present has a criminal record clearance on file, but is not associated to the facility. Civil penalty issued. A blank copy of a Criminal Background Clearance Transfer Request (LIC9182) and the facility's current guardian roster was provided to Adminstrator Bansode for reference. Per Administrator Bansode, S1 has worked at the facility for approximately three (3) years. LPA verified S1 has a current CPR/first aid certification. Yard/Outside Area: A brick wall secured the backyard. All outdoor pathways were free of obstructions. No bodies of water were observed. Based on the aforementioned, LPA issued a civil penalty along with two (2) deficiencies faulting the facility. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Bansode along with an LIC809-D, LIC421BG, and Appeals Rights.