Routine inspection (multi-day)·July 31, 2024

Licensing Program Analyst (LPA), Stephanie Martinez, continued a required annual inspection at the facility that was started on 06/18/2024. The LPA was allowed entrance into the facility and met with Administrator, Ma Satchel Lecita. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: Physical Plant: The facility consists of eight (8) resident bedrooms, three (3) bathrooms, a garage, an open kitchen and dinning areas, a living room area, an office area, a laundry room, 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 Lecita, 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 smoke and carbon monoxide devices were tested by the Administrator and was observed to be in operating condition. The home was kept clean, organized and free of any odors. Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. 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 is currently one (1) residents in care receiving hospice services. There is a disaster and mass casualty plan in place. Three out of three staff members (S1 - S3) do not have current First Aid training on file. A citation will be issued. Two out of two staff members (S2 and S4) did not have the 20 hours of required annual training (Dementia, Postural Supports, Restricted Health Conditions or Hospice). A citation will be issued. One out of one staff members (S2) does not have the complete 10 hours of initial medication training. S2 only has 2 hours of medication training from 05/30/2023. According to Administrator, S2 started employment on 05/30/2023. A citation will be issued. Five out of five residents (R1 - R5) did not have a written record of care on file. A citation will be issued. Two out of two residents (R1 and R5) have a restricted health condition. According to staff the residents can manage their own treatment/care; however, neither had documentation on file indicating the residents can manage their own health conditions. A citation will be issued. One out of one residents (R6) did not have a hospice care plan on file. A citation will be issued. Medication Review: The LPA inspected resident medications. Medications were observed to be well organized, appropriately labeled and inaccessible to unauthorized individuals. Two out of two residents (R1 and R7) medications were being stored in weekly medication containers. A citation will be issued. An exit interview was conducted with Administrator Lecita in which this report was reviewed and a copy was provided, along with the LIC 811s, LIC 9098, and instructions on appeal rights.