Routine inspection·April 5, 2024

Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection to the facility. The LPA was allowed entrance into the facility and met with Licensee, Salote Tupou, and Administrator, Vaiasini Tupou. The LPA informed the Licensee and Administrator of the purpose for the visit. The facility currently has an approved Hospice Waiver for one (1) residents. The inspection included the following: Physical Plant: The facility consists of three (3) resident bedrooms, one staff room, a dinning area, a living space, an open kitchen, and an outdoor and patio space, with sufficient seating and space for activities. There are no bodies of water located on the property. According to Licensee Tupou, 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 present. The carbon monoxide and smoke detectors were tested by the Administrator and were observed to be in operating condition. The home was kept exceptionally clean and free of any odors. Food Service: There is a minimum of 2 days of perishable foods and 1 week's supply of non-perishable foods. Sufficient supplies were observed to be available for resident use. 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. Staff responsible for direct care and supervision have current first aid and CPR training. Dementia care training was observed to be available and complete. The facility was not operating beyond the conditions specified on the license. The LPA was informed by Administrator Vaiasini that there are currently no resident in care who are receiving hospice services services. There is a disaster and mass casualty plan in place. Proof of emergency drills were observed on file. Facility records were kept well organized. Medication Review: The LPA reviewed medications for two residents. The LPA observed four medications found not to be labeled. The medications were being centrally stored for Resident Two (R2). All four medications were listed on R2's medication list. This violation poses a potential health, safety and personal rights risk to the resident in care. A citation will be issued. An exit interview was conducted with Licensee Salote Tupou, in which this report was reviewed and a copy was provided, along with the LIC 811 and instructions on appeal rights.