Routine inspection·April 26, 2024

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Jeannette Rodriguez who was informed of the purpose of the visit. At the time of the visit there was (1) staff and (5) residents present. The facility is a one story home with (5) bedrooms and (3) bathrooms for clients. No pool or firearms are present at the facility. The facility is a residential care home for the elderly approved for (6) non-ambulatory. LPA found through records review and interview that (1) resident was confirmed to be bedridden. The facility was cited for not having the appropriate fire clearance, Plan of correction was created. Infection Control: The LPA observed the hand hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan. Physical Plant: Physical plant was observed to be clean and fixtures and furniture were in good repair. LPA observed client bedrooms and bathrooms, kitchen, living areas, and out door area. No health and safety issues were observed. The carbon monoxide detector was functional and hot water temperature was 120F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Perishable and non-perishable items were observed to be in required amounts. Record Review and Resident/Staff Files: LPA reviewed staff files and training, and resident files. LPA reviewed (5) resident files, (3) did not have a written care plan. The facility was cited and a plan of correction was created. LPA review the staff training, all staff have completed required training corroborated through interview. The documentation for the training will be sent to the LPA by Monday 4/29/2024. Health Related Services/ Incidental Medical Services: All resident medication was locked in a hallway closet. Medication was accounted for on the MARS list. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The facility has not conducted a fire drill since being licensed. Technical note was documented for staff to conduct drill and send to LPA by 4/29/2024. An exit interview was conducted where a copy of this report was reviewed and provided to Administrator, Jeannette Rodriguez.