Routine inspection·July 16, 2025

On 7/16/2025, Licensing Program Analysts, Kimberly Viarella and Arvin Villanueva (LPAs) arrived unannounced at this facility to conduct their annual inspection visit. LPAs initially met with staff on duty (S2) and stated the purpose of the visit. The Administrator Beatrice Clark (S1) was notified and arrived later. Overview : Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents. 5 may be non-ambulatory. Bedrooms 1, 2, 3 and Master bedroom approved for non-ambulatory. Bedroom 4 approved for ambulatory only. Facility has hospice waiver for 2 residents. Initial Observation: Upon arrival, LPAs observed 3 residents having their morning meal at the dinning table. Present during this visit were 6 residents in care with 1 staff on duty (S2). There was an outside agency staff assisting one resident. The room temperature was at 72 degrees Fahrenheit. Physical Inspection and Operational : Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA inspected 5 resident bedrooms. Master bedroom is occupied by 2 residents. Bedroom #4 is currently being occupied by a non-ambulatory resident. LPA measured the hot water temperature in the 1 of 2 bathrooms to be at 107 degrees Fahrenheit. The light switch in the hallway bathroom was observed to be in disrepair. Also inside the hallway bathroom, LPAs found scissors under the sink cabinet, unlocked and accessible to residents in care. The bathroom inside the master bedroom, LPAs found a disinfectant spray inside the sink cabinet that was unlocked and accessible to residents. Also inside the bathroom in the master bedroom, LPAs observed the shower area to not equipped with grab bars. The master bedroom bath also has a closet which contains 2 Hoyer lifts. {Con't to 809-C} {Con't from 809} Fire extinguisher was observed in the kitchen area and hallway and was last inspected on 4/15/2024. Smoke and carbon monoxide detectors were observed throughout, tested and found operable during this visit. Fire door leading to the resident bedrooms were observed to be propped open with a sandal. In the kitchen area, LPA observed sufficient seven day non-perishable and two day perishable food supplies. Pantry was observed to be stocked with non-perishable food items. Kitchen refrigerator and freezer were maintained at regulatory temperature. Inside the kitchen refrigerator, LPAs found resident medication that was accessible to residents in care. Per interview with S1, staff lock the refrigerator. During this visit, S1 purchased a lock box for the medication. Outdoor area was inspected. LPA observed outdoor furniture for resident use. Ramps were observed to be in good repair at this time. Emergency walkways were observed to be unobstructed. Fence and gates were in good repair at this time. Record Reviews: Review of 6 of 6 resident files (R1 - R6) was conducted, include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. LPAs noted some issues. Medication review of 4 of 6 residents include review of physician orders for over-the-counter medications. LPAs noted some issues. Per S1, they do not have Centrally Stored Medication Record available for review during this visit. Review of 2 staff files (S1 and S2) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. S2 did not have a current first aid certificate on file available for review during this visit. Fire drill/disaster drill records were not available for review during this visit. Infection Control Plan and Emergency Procedure Plan were not available for review during this visit. First Aid kit was reviewed and found to be incomplete at this time: needs bandages and first aid manual. LPA was provided a copy of current Liability Insurance Certificate, LIC500 and LIC308 during this visit. Interviews: LPA interviewed 2 staff and 2 residents during this visit. Based on today's visit, this annual needs continuation. Exit interview was conducted with S1. A copy of the report was provided upon exit.