Routine inspection·April 3, 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 Administrator, Nelly Nunez. The LPA informed the Administrator of the purpose for the visit. The facility currently has an approved Hospice Waiver for six (6) residents. The inspection included the following: Physical Plant: The facility consists of six (6) resident bedrooms, an office, one dinning area, two living spaces, an open kitchen, a laundry area, and a patio with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator Nunez, there are no weapons 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 and shower used by residents. Resident showers have non-skid mats available. The carbon monoxide and smoke devices were tested by the Administrator and were found to be in operating condition. The home was kept free of any odors. The home was exceptionally clean and well organized. Food Service: There is a minimum of 2 days supply of perishable foods and 1 week's supply of non-perishable foods available. Staff Two (S2), who was observed to be cooking at the time of the LPA's visit, appeared to be following proper hygiene practices. In addition, proof of food handling training was observed on file for S2. 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 conducted for S2. No proof of postural support related training, restricted health conditions related training or hospice related training was observed on file for S2. This posses a potential threat to the health, safety and personal rights of the residents in care. A citation will be issued. The facility was not operating beyond the conditions specified on the license. The LPA was informed by Administrator Nunez there is currently one resident in care who is receiving hospice services. A copy of the resident's Hospice Care Plan was observed to be available. Proof of emergency drill training was observed on file. Medication Review: The LPA reviewed medications for R1. The LPA observed three of R1's medications to not be listed on the Centrally Stored Medication list retained by the facility. This posses a potential threat to the resident's health and safety. Therefore, a citation will be issued. An exit interview was conducted with Administrator Nunez in which this report was reviewed and a copy was provided, along with the LIC 811 and instructions on appeals rights.