Routine inspection·April 8, 2024

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual and met with Dan Mititi, Administrator. Caregiver, Harlene Henry was also present. LPA observed all (4) residents to be in their rooms at the start of the inspection. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (3). Currently, there is (1) resident on hospice. LPA and Administrator toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms (1) shared resident bedroom, (2) resident bathrooms, (1) staff room, kitchen, laundry area, and office area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. There is sufficient 2+ day perishable and 7+ day non-perishable supply of food. Sharps are locked in the kitchen, medications are locked in the office area, and toxins are locked in the outside laundry area. The inside temperature measured 71*F, and the hot water temperature measured 106*F in the kitchen. Facility conducts quarterly fire drills. Smoke/monoxide alarms are working. Fire extinguisher was last serviced 10/23/2023. There are sufficient towels/linens/PPE/paper and incontinent products. All required postings are in the common area. LPA observed (1) unlocked gate from the outside patio and also covered patio seating. There is an empty pool that is locked and gated.First aid kit is complete. LPA reviewed/approved the Infection Control Plan and found it complete. Emergency Disaster Plan was also reviewed. LPA reviewed (3) resident files and found them to be complete with current physician's reports and care plans. Medications were reviewed for (2) residents and orders matched medications being administered. Medication documentation is current and PRN dosages are being recorded. LPA reviewed (3) of (3) staff files, which were organized and complete. Current training documentation, including First Aid/CPR, was on file. All staff are cleared and associated to the facility. Discussed Guardian updates to manage roster. RCFE Administrator certificate #6006514740 is pending renewal. LPA obtained an updated copy of the LIC308, LIC500, and current of liability insurance. There are no deficiencies issued during today's inspection. Exit interview. Copy of report provided.