Routine inspection·October 10, 2024

Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection to the facility. The LPA was allowed entrance into the facility and met with Administrator, Alicia Pergantis. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: Physical Plant: The facility consists of four (4) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, storage areas/closets, a kitchen and dinning area, a living room space, a laundry room, a garage, and a patio and yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator Pergantis, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats or strips present. The carbon monoxide and smoke detector were tested by staff and observed to be in operating condition. Food Service: There is a minimum of 2 days supply of perishable foods and 1 week's supply of non-perishable foods available. A variety of food was available and stored in a safe and healthful manner. Sufficient dinning supplies were available for residents in care. Record Review: There is a disaster and mass casualty plan in place. The facility has a copy of the Plan of Operation available. The Administrator reviewed the facility's profile and reported all information is accurate and up to date. All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Dementia care training, postural support training, restricted healthcare training and hospice training was not observed on file for Staff Two (S2) or Three (S3). S2 was interviewed & reported they have had dementia training (3 hours) several months ago. S2 could not recall when other training was completed. S3 was interviewed & could not recall when the training was completed. A citation will issued. The facility was not operating beyond the conditions specified on the license. The facility currently has an approved Hospice Waiver for five (5) residents and there are currently three (3) residents in care receiving hospice services. Six (6) out of six (6) residents did not have a current written record of care on file. A citation will be issued. Medication Review: The LPA inspected medication storage areas. Medications were observed to be inaccessible to unauthorized individuals. Medication Administration Records (MARs) are being maintained by the facility. The Administrator was also issued Technical Advisories and Violations for violations that did not pose an immediate threat to residents in care. An exit interview was conducted with Administrator Pergantis in which this report was reviewed and a copy was provided, along with the LIC 858, LIC 859 and instructions on appeal rights. LPA addressed Administrator questions relating to the report.