Routine inspection·April 18, 2023

Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection on 04/18/2023 at 1:10 PM. LPA Lee met with licensee Yacub Lucas and explained the purpose of the visit. Licensee assisted with today’s visit. The facility has one main Covid-19 screening entry point. The facility has Covid-19 posting throughout the facility. The furniture is spaced six feet apart, and the facility does daily cleaning. The facility has a 30-day supply of PPE. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. The facility has two public telephones one in the common area and one the kitchen area. The facility has the required posters posted in the facility. This facility is a single story building licensed to serve six (6) non-ambulatory residents with two (2) hospice waiver. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee observed sufficient seven-day non-perishable and two-day perishable food supplies. The resident bathroom water temperature measured at 131.9 degrees Fahrenheit which is not within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in good repair. Facility thermostat observed at 70 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to clients. LPA Lee check MAR sheets along with medications and it was complete. First aid kit was incomplete; the first aid kit was missing a manual. Licensee purchased a new first aid kit from amazon today 04/18/2023 at 2:30 PM and showed purchased confirmation to LPA Lee. Licensee stated he will send pictures of the First Aid manual to LPA Lee when it arrives tomorrow. LPA Lee requested client and staff files for review. Continued LIC 809-C LPA Lee reviewed (2) client files and (2) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks fingerprint cleared and associated to the facility. LPA Lee verified staff training for staff file reviews and learned that staff (S1) First aid/CPR has expired on 03/22/2023. The facility has infection control plan and has an emergency disaster plan. The following documents were provided to LPA Lee during today’s visit: (1) LIC 308 Designation of Administrative Responsibility (2) LIC 500 Personnel Report (3) Proof of Current Liability Insurance (4) LIC 610 Emergency Disaster Plan As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.