Routine inspection·April 24, 2025

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. 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 outdoor area. The carbon monoxide detector and smoke alarms were functional. The hot water temperature was read at 120F. LPA observed the hazardous items like cleaners and knifes were kept locked and inaccessible to residents. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and safe environment. The facility met the 2-day supply of Perishable and 7-day supply of non-perishable food items. Record Review and Resident/Staff Files: The administrator's file, staff file for Staff #3 (S3), Staff #4 (S4), Staff #5 (S5), and Staff #6 (S6) were incomplete at the time of the time of the visit. A deficiency was cited and plan of correction was created. LPA reviewed (5) resident files which were also incomplete. A deficiency was cited and a plan of correction was created. Resident #5 (R5) did not have a death report, based on licensee interview and record review there was no incident death report received by the regional office. A deficiency was cited and a plan of correction was created. A deficiency was cited for staff training such as orientation, medication, CPR and first aid, and 40 hour annual training to be documented and sent to the LPA for review. The staff schedule has staff scheduled to work at the facility who are not associated to the facility. A deficiency was cited for the staff schedule to be redone with cleared staff and staffing levels to meet the residents needs. A deficiency was cited for Staff #1 (S1) who was not associated to the facility and had worked at the facility for (1) month. A deficiency was cited for Staff #2 (S2) who had worked at the facility for (6) months and was not fingerprint cleared. Staff observed during the visit were fingerprint cleared. Health Related Services/ Incidental Medical Services: All resident medication was locked in a hallway closet. Medication was accounted for on the Medication Administration Record (MAR) and observed medications stored in originally received containers. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The last documented fire drill was conducted on 11/25/2024 which did not meet the department requirements. A deficiency was cited and a plan of correction was created. The facility exits were observed to be clear of obstructions. An exit interview was conducted where a copy of this report, LIC809-D pages and appeal rights were reviewed and provided.