Routine inspection·November 20, 2024

On 11/20/2024, Licensing Program Analysts (LPAs), Andrei Castillo and Seo Jeon arrived at the facility unannounced to conduct the required annual inspection. Upon entry, LPAs were greeted by Caregiver, Emelita Aragon and informed her of the purpose of the visit. Administrator, Marilyn Ponteres arrived a few minutes later. At the time of the visit, there were two staff members and four residents present. LPA conducted a tour of the facility with the Caregiver, reviewed facility documents and conducted interviews. The following is a summary of the visit: Facility Overview: The facility is a one-story home with six bedrooms and five bathrooms, including an attached garage. Resident bedrooms had the required bedding, furniture, and lighting. Facility sketch, exit routes, personal rights, “If you See Something, Say Something,” LTC Ombudsman, complaint information and emergency phone numbers were observed posted in the facility. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care. Infection Control: There were hand hygiene and hand washing stations, and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: Floors, windows, and doors were clean and well-maintained. Furniture and fixtures were in good condition. The outdoor area which is a gated backyard was free of hazards and has a shaded area with outdoor furniture. Laundry equipment was in good working condition. LPA observed fully charged fire extinguishers. Disinfectants, cleaning solutions, and sharp and dangerous objects were securely locked and Cont. LIC 809-C inaccessible to residents. The smoke and carbon monoxide detectors were tested and operational, and the hot water temperature was measured at 120 °F which is within the required limits. Safety night lights were observed throughout the facility. There were no bodies of water located on the property. According to the Administrator, there are no firearms or ammunition on the premises. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. Administrator’s certificate has been expired since 08/18/2023. A citation was issued. Record Review and Resident/Staff Files: LPA reviewed files for two staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Four resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for four residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan. The required quarterly fire drill has not been conducted. A citation was issued. All facility indoor and outdoor passageways and exits were clear of obstructions and or debris. There was a first aid kit with a manual. Citations were issued during the visit. An exit interview was conducted, and a copy of this report, LIC 809-D and appeal rights were reviewed and given to Administrator, Marilyn Ponteres.