Routine inspection·March 15, 2024

Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Licensee, Jane Mikenas, who was informed of the purpose of the visit. At time of visit there were (6) clients and (3) staff present. The facility is a one story home with licensed capacity on the first floor with (5) bedrooms and (2) bathrooms. The facility does not have a pool or fire arms. The facility is a residential care facility for the elderly serving elderly ages 60 and above. LPA 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 a infection control plan on file. 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 carbon monoxide detector were operational. 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 food items. Record Review and Resident/Staff Files: LPA reviewed staff files and training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All client medication was locked in a hallway closet. LPA reviewed client medications and found that MARS and medication had discrepancies. LPA observe medication #1 (M1) was not punched but was documented on MARS as given. Medication #2 (M2), and Medication #3 (M3) and Medication #4 (M4) were documented as given, but the medication was still observed in the bubble pack on this date. Medication #5 (M5) indicated to have given for (7) days, had been ordered by the physician to be given for (5) days. Based on staff interviews, medication errors occur and staff are trained every (3) months. The deficiency was cited for medication administration and plan of correction was created. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted on 2/2/2024. An exit interview was conducted where a copy of this report, LIC809-D, LIC811, appeal rights and LIC9098 were reviewed and provided to, Licensee, Jane Mikenas.