Routine inspection·April 17, 2024

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator Janard Lansangan and informed her of the purpose of today's inspection. Below is a summary of what was observed: Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include soap and paper towels at hand washing stations, and hand washing guides posted above sinks. Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 113.9 degrees. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. LPA Colvin observed an in-ground pool in the backyard, which was gated and locked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. Knives and other sharp objects are kept locked away and out of resident reach. Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 non-ambulatory residents, one of which may be bedridden. Facility has a hospice waiver for 2 residents. Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that the facility has an Administrator with a current Administrator Certificate. LPA Colvin reviewed staff records and confirmed current CPR/First Aid Certification as well as training relevant to the facility and residents' needs. All staff have criminal background clearance that has been transferred to the facility. Resident Records: LPA Colvin reviewed the files for all 6 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin observed that three residents (R1, R2, & R3) diagnosed with Dementia have Physician's Reports that are over one year old. Deficiency cited. Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file. LPA Colvin observed that the facility has not documented an Emergency Disaster Drill since 2020. Deficiency cited. Planned Activities: LPA Colvin confirmed with interviews of staff and residents that the facility provides activities for residents to engage in and are tailored to their interests. An exit interview was conducted with Administrator Janard Lansangan and a copy of this report, LIC809D, LIC9098 Proof of Corrections, and appeal rights were provided.