Routine inspection (multi-day)·January 12, 2024

Licensing Program Analyst (LPA), Stephanie Martinez, returned to the home on the above date to continue the annual inspection that was started on 12/29/2023. The visit was unannounced. The LPA met with Administrator, Brevet Dao, shortly after the start of the visit. Food Service: There is a minimum of 2 days of perishable foods and 1 week's supply of non-perishable foods available. All readily perishable food or beverages capable of growth of micro-organisms are being stored in covered containers at appropriate temperatures. The kitchen was observed to be maintained in a clean and organized state. Record Review: Staff have criminal record clearances, 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 training. Administration: There is a disaster and mass casualty plan in place. The facility has an approved hospice waiver for six (6) residents. All services requiring specialized skill are being performed by personnel qualified as appropriately skilled professionals. Medical Related Services: There are no persons who have a prohibited health condition admitted at the facility. The LPA conducted a medication audit and observed violations; medications were being transferred from their original containers into weekly medication containers. This poses a potential threat to the health and safety of residents in care. A citation will be issued. An exit interview was conducted with Administrator Dao; this report was reviewed and a copy was provided.