Routine inspection·April 3, 2024

On 04/03/2024 at 8:21 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care staff, Tanisha Linzy, who then called administrator, Hong Trinh. Administrator and Licensee arrived approximately an hour later. LPA Lee explained the purpose of the visit. The Licensee and Administrator assisted with today’s visit. Administrator certificate # is 6042113740 and will expire on 12/4/2024. The current census is 30 residents with 7 facility staff which consist of 1 housekeeper, 1 Med-tech, 2 caregiver, 2 cook and the administrator and licensee. This facility is a two story building licensed to serve thirty-six (36) non-ambulatory residents, which 4 may be bedridden and approved for 2 hospice waivers. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, residents’ bedroom, residents’ bathroom, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be clean and in good repair. LPA Lee observed the back facility, Terrence Hall to have a strong urine odor as LPA Lee entered the building. The urine order was noticeable upstairs and downstairs of the building. In addition, when LPA Lee toured the Terrence building LPA Lee observed the following residents’ room to have a very strong urine odor: residents bedrooms number # 14, 20, 21, 27 and 24. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee toured the kitchen and observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 114.3 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. Continued LIC 809-C The fire extinguisher is located in the kitchen and common area and was last serviced on 12/22/2023. LPA Lee observed the facility has a has a public telephone in the kitchen and office. The facility has the required posters posted. The facility has an infection control plan and an emergency disaster plan. Facility thermostat observed at 72 degrees Fahrenheit. LPA Lee observed toxins located in laundry and kept locked and inaccessible to residents. LPA Lee observed sharp knives kept locked and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to resident. LPA Lee along with Med-Tech Tanisha Linzy reviewed and compared 5 medication administration record (MAR) and it was not complete. MAR logs was missing staff initials. LPA Lee and Med-Tech Tanisha also audit 2 resident medications and it was learned that the medication is either not given to residents or are missing. The first aid kit was checked and contained all the required components. LPA Lee requested resident and staff files for review. LPA Lee reviewed 10 resident files and four resident's LIC 625 are missing resident's signature. LPA Lee reviewed 3 staff files, and they were complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following documents were given to LPA during today's visit. (1) LIC 308 Designation of Administrative Responsibility (2) LIC 610 Emergency Disaster Plan (3) Proof of Current Liability Insurance 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.