Routine inspection·April 16, 2025

On 04/16/25, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator Lezel Bello and explained the purpose of the visit. Administrator certificate # is 6051174740 and expired on 02/20/25, however, administrator renew her administrator certificate on 02/06/25, and it is currently pending. The current census is 34 with 8 facility staff. This facility is a two story building with two additional separate buildings licensed to serve thirty-six (36) non-ambulatory residents, of 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, resident bedrooms, resident bathrooms, laundry room, staff office, medication 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 bedrooms to be properly furnished with appropriate bedding and lighting. LPA Lee inspected residents bedroom in the main building, wall building and Terrence building and observed resident bedroom #10 to have an incontinence smell. During the visit, LPA Lee observed a facility staff cleaning and mopping resident room #10. There are no bodies of water present. LPA Lee toured the kitchen and observed sufficient seven day non-perishable and sufficient two day perishable food supplies. Hot water temperature was measured at 112.6 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and were observed to be stable and in good repair at this time. Non-slip mat was observed only in 2 bathrooms out of 4 resident’s bathrooms. Continued LIC 809-C Smoke and carbon monoxide detectors are in compliance with fire safety. Multiple fire extinguisher is located through the facility and in the separate buildings and was last serviced on 12/03/24. The last fire drill was conducted on 03/21/25. The facility has the required posters posted. Facility thermostat was observed at 74 degrees Fahrenheit. LPA Lee observed toxins kept locked and inaccessible to residents. LPA Lee observed sharp knives kept locked in the kitchen cabinet and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA and the administrator also tested 8 residents call pendants, which appeared to be functioning properly and emit an auditory signal to produce an auditory signal loud enough to summon staff. LPA reviewed 2 out of 5 residents oh hand medications and medication administration record (MAR) and it was incomplete. Two of the resident’s medications are found in the resident’s medication box; however, they are not documented in the MAR logs. The first aid kit was checked and contained the required components. LPA Lee requested resident and staff files for review. LPA Lee reviewed 5 resident files, and they were complete. LPA Lee reviewed 3 staff files, and it was also 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 was provided to LPA Lee during today’s visit. (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610 Current Emergency Disaster Plan (5) Proof of Current Liability Insurance As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with administrator Lezel and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.