Routine inspection·December 4, 2023

On 12/04/23 Licensing Program Analyst (LPA) Javina George arrived unannounced to the facility noted above to conduct an annual inspection. LPA was greeted and granted entry by Caregiver Bituin Mendoza. LPA met with the Administrator Annalisa Blancaflor, who arrived after LPAs arrival. Below is an account of LPAs observations of the conducted inspection: Physical plant: The facility was observed to be within the licensed capacity (6). At the time of LPAs visit all residents were asleep taking their afternoon naps. LPA was able to successfully conduct one (1) resident interview. LPA was unable to check the mattresses. LPA observed for the resident bedrooms to have night stands, storage space, and sufficient lighting. The facility temperatures were comfortable for residents in care. LPA measured the hot water temperature in two (2) resident bathrooms, initially the water temperature was too hot, the water heater was adjusted and the water temperature ranges were retested and observed to be within regulatory limits of ranging from 115-117 degrees Fahrenheit. The carbon monoxide and smoke detectors were tested and were observed to be operable. The facility was stocked with a 2-day supply of perishable and 7-day supply of non-perishable food items that were labeled appropriately. Personnel: The facility administrator certificate expired and the renewal packet was sent off the month after it was due (10/2023). The administrator will send proof of completion to the department by 5pm on 12/5/23. In addition the Administrator's CPR/First Aid expired on 06/19/2020. Deficiency cited . There is a locked and centralized storage area for medications, which is located in the kitchen above the microwave. The facility had a designated area for resident files and staff files, however there were no other staff files available for review but the Administrator's. Per the Administrator the facility is in the process of updating the staff files which is why they were not at the facility. The administrator is to submit proof of staff #1 (S1) employee file to the department by 5:00pm on 12/5/23. All staff present have a criminal record clearance on file and are associated to the facility. The facility was not observed to have all the required postings however did have such as Ombudsman poster and PUB475. See citations below. The facility was also equipped with one (1) fire extinguisher and one (1) complete first aid kit as well as the first aid manual. LPA inspected the outdoor area of the facility. The facility has a covered patio. The facility is in compliance as the business' governing body is active and functioning. The licensing renewal fees are due by 12/18/23, and was discussed with the Administrator. The following citation(s) are being issued as the facility has not been conducting emergency disaster drills on a quarterly basis nor documenting the conducted drills. In addition the facility did not have personnel files available for review at the time of LPAs visit. The administrator's CPR/First Aid expired 06/19/2020. Further the facility does not have a completed Emergency Disaster Plan (LIC 610E). The citation(s) can be found on the attached 809D. An exit interview was conducted and a copy of the report, 809D, and appeal rights were reviewed and provided to Annalisa Blancaflor, administrator.