Inspector’s narrative
What the inspector wrote
On 01/09/25, at 1:00 PM, Licensing Program Analyst (LPA) Pang Lee arrived announced to conduct a Pre-Licensing Inspection of the facility to assess compliance with Title 22 regulations. LPA Lee met with Licensee Violet Mubeezi who assisted during the inspection. The applicant is seeking licensure for a 6-bed non-ambulatory Residential Care Facility for the Elderly (RCFE), which will accept and retain residents, including bedridden individuals. Bedrooms 1, 2, 3, 6, 7, and 8 are designated for non-ambulatory residents, while bedrooms 4 and 5 are designated for staff rooms. The facility also has a dementia care plan on file. The facility will provide 24/7 care and supervision, with live-in staff. At the time of the inspection, there were no residents present. A brief interview was conducted with the applicant. Violet Mubeezi will be the Administrator of the facility. Her administrator’s certificate #7034316740 is valid until 09/09/25. The facility has an infection control plan and an emergency disaster plan, both of which have been submitted to Licensing for approval.
LPA Lee toured the facility with the applicant and noted the presence of 4 cameras throughout the premises. However, these cameras were not included in the facility's sketch and plan of operation. Additionally, the facility’s physical layout did not match the submitted sketch, as there are rooms designated for laundry and staff office that were not accounted for in the submitted facility sketch. LPA Lee also observed several picture frames stored behind a sofa in the entrance area. During the kitchen inspection, LPA Lee reviewed the cabinets and drawers. The facility had sufficient silverware, plates, and utensils for the residents. Knives, cleaning agents, and bleach were properly secured and inaccessible to residents. However, the cabinet where knives were stored was in disrepair. The food storage area, including the facility's refrigerator, was functional and in good condition.
Continued LIC 809-C
However, there was insufficient 2 days perishable food supplies, as only condiments, a loaf of bread, and a dozen eggs were present in the refrigerator. The common and dining areas were appropriately furnished to meet the needs of residents. A telephone was available in both the kitchen and common area for resident use.
The facility’s smoke detectors, carbon monoxide detectors, and fire extinguisher were all in good condition. The fire extinguisher had been serviced on 09/26/24. LPA Lee did not observe a linen closet or designated storage for linens. Some linens and blankets were stored in trash bags and laundry baskets in multiple residents’ rooms. Additionally, several residents' rooms did not have sufficient furniture, such as chairs and drawers, to meet residents’ needs. The bathrooms in the residents' rooms did not have non-slip mats and grab bars. LPA Lee also observed staff personal belongings in resident rooms #6 and #8. The water temperature was measured at 112.5°F, and the facility temperature was recorded at 73°F which are withing the required regulation. The centrally stored medication areas were locked, and the first aid kit was complete. Hygiene items were available for residents, and there was a designated area for both resident and staff files. LPA Lee did not observe the required complaint poster (PUB 475) displayed in the facility. Activity supplies for residents were available. LPA Lee also toured the garage, where miscellaneous items were stored. The administrator was advised that the cluttered area would need to be cleaned up and decluttered.
In the outdoor areas, LPA Lee noted the presence of various items, such as a broken microwave, picture frames, wood planks, a broken window screen, bedrails, racks, and shovels, in the courtyard. Additionally, exposed wire was observed on the backyard porch, along with sharp metal attached to the fence. While the emergency exits were unobstructed, the back porch posed a health and safety concern, as it was 22 inches high and lacked rails to prevent residents from falling. Furthermore, there was an accessible crawl space on the side of the facility, which could present a safety risk to residents.
The applicant will work on the following deficiencies observed:
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Licensee will ensure that an updated plan of operation to include the 4 cameras in the facility. A plan of operation will also be submitted to include the purpose of the camera, who can view the camera, how long is the recording and that the camera can NOT have audio.
Continued LIC 809-C
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Licensee will ensure that an updated facility sketch to include the laundry room and designated office.
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Licensee will ensure that personal belongings in residents’ bedrooms are removed.
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Licensee will ensure that resident’s room are equipped with drawers and a chair.
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Licensee will ensure that all residents bathrooms showers have non-slip mats and grab bars.
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Licensee will ensure that the cabinet in the kitchen where the knifes are store and the cabinet in resident bathroom 3 are in good repair.
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Licensee will ensure that rolled carpets, mattress, bedframes, boards, miscellaneous items in resident bedrooms are remove.
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Licensee will ensure that a complaint poster PUB 475 in the size of 20”X26” is posted.
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Licensee will ensure the crawl space on the side of the facility is made inaccessible to residents in care.
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Licensee will ensure that all the exposed wires, wood planks and miscellaneous items in the courtyard are disposed.
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Licensee will endure that the facility has sufficient 2 days perishable food at all times.
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Licensee will ensure that there is a rail install in the back porch to prevent residents from falling over.
The Applicant has not passed the pre-licensing component of the application process. The applicant will correct deficiencies and inform LPA Lee when the corrections have been completed. An exit interview was conducted, and a copy of this report was provided to the applicant.
