Routine inspection·January 23, 2024

Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Administrator, Cori Cooper who was informed of the purpose of the visit. At time of visit there were (6) clients and (2) staff present. The facility is a one story home with (4) bedrooms and (3) bathrooms with attached garage. The facility does have a pool which has a locked gate surrounding it. No fire arms are kept at the facility. The facility is designated as a residential facility for the elderly serving elderly ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents, and observed the following: Infection Control: LPA observed hand hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has an infection control plan that is documented with the department, however the administrator was unable to provide it during the visit for review. Technical note was documented for this. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The carbon monoxide detector was operational during the visit. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Record Review and Resident/Staff Files: LPA reviewed staff files, training, and criminal clearance. LPA met with Staff #1 (S1) who was not on the staff roster, and was alone with residents. LPA checked S1's criminal record clearance during the visit, who possesses a cleared background. The administrator was able to show LPA S1's file during the visit, and was informed that S1 had started (4) days ago. S1 needs completed physical, orientation training and completed transfer. Deficiencies were cited and plan of correction was created with administrator. Client files were reviewed and possessed all required paperwork. Client #1 (C1) had LIC602 that was not dated or signed by a physician. Technical note was documented for this to be completed. Admission agreement for C1 was not signed by facility representative. Administrator signed the agreement during the time of the visit. Technical note was documented for this as well. Health Related Services/ Incidental Medical Services: All client medication was locked in a kitchen cabinet. LPA reviewed client medications for C1 and found medication for today's date was not initialed as given. LPA also found PRN medications for C1 did not have a physician's order with C1's medical provider. Deficiency was cited for this and plan of correction was created with administrator. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA was informed by administrator that the last drill was conducted October 2023, documentation was unable to be provided during the time of the visit for the drill. Deficiency was cited and plan of correction was created for drill to be conducted and documented. An exit interview was conducted where a copy of this report, along with deficiency pages, appeal rights, and technical notes were provided to Administrator, Cori Cooper.