Routine inspection·March 27, 2024

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with staff Higinio Alvarez and informed him of the purpose of today's inspection. Below is a summary of what was observed: Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include: soap and paper towels at hand washing stations and hand washing guides posted. Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 100.9 degrees. Deficiency cited. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives were locked away from residents' reach in a drawer in the kitchen. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. LPA Colvin observed a latch on the refrigerator which is capable of holding a lock to secure the refrigerator. Since LPA Colvin did not observe a lock on the latch, LPA Colvin is only issuing a Technical Assistance Advisory Note , recommending the facility to remove the latch. Planned Activities: LPA Colvin observed the facility's Activity Calendar as well as residents engaging in their own private activities in their rooms. Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file with the Department, though staff present at the facility could not locate the file in the facility. Operational Requirements: The facility is licensed for 6 non-ambulatory residents and has a hospice waiver for up to 3 residents. LPA Colvin observed through review of the resident files that one resident (R1) is bedridden. The facility does not have bedridden fire clearance. Deficiency cited. Violations of the facility's fire clearance is considered a serious violation and is subject to an immediate $500 civil penalty , which LPA Colvin will be assessing today. Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that the facility has an Administrator with a current Administrator Certificate, though Licensing has not completed processing to update the Change of Administrator. LPA Colvin additionally observed that the acting Administration, Aurora Cuasay, is not associated to the facility. Deficiency cited. When there is a violation of criminal background clearance (such as staff not being associated), a civil penalty is assessed in the amount of $100 per day, per staff member, with a limit of $500 per staff member being assessed, unless the facility has repeated this violation in the last 12 months. Aurora Cuasay has been acting Administrator for the facility since late 2023, s o LPA Colvin will be issuing $500 in civil penalties ($100 a day x 5). LPA Colvin additionally observed that at least one direct care staff (S1) does not have current CPR/First Aid Certification, as there's expired in 2023. Deficiency cited. LPA Colvin was unable to verify staff training as staff files were not available to LPA Colvin during today's inspection. Deficiency cited. Resident Records: LPA Colvin reviewed the files for all 4 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. Resident files appeared to be complete and up to date. Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet in the kitchen and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions . An exit interview was conducted with staff Higinio Alvarez (and Administrator Aurora Cuasay via telephone) and a copy of this report, LIC809D, LIC421BG, LIC421IMs, LIC9102, LIC9098 Proof of Corrections, and appeal rights were provided.