Routine inspection·March 27, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete a required annual inspection and met with Veronica Morales, Administrator. LPA stated the reason for today's inspection. The facility is licensed for (49) residents, (34) of whom may be non-ambulatory and (15) may be bedridden. There is an approved for hospice wavier for (17) residents and delayed egress exit doors. There are currently (6) residents on hospice. LPA and the Administrator toured the interior and exterior of the facility including the common areas, (5) resident rooms, medication room, (2) dining rooms, activity room, salon, kitchen and staff lounge. LPA observed the facility to be clean, in good repair, and odor-free. Fire extinguishers observed throughout and were last serviced on 7/23/24 There are (3) exit doors, including the front entrance door, equipped with an egress door alarm. Alarms on door alerts and gates are checked daily. There is an enclosed courtyard with seating for residents. The inside temperature measured 73*F. Hot water was checked in (3) resident rooms and measured 116/117*F in each room and is checked weekly. Each resident room has a pull cord in the bathroom and one for each resident near their bed. There is sufficient 2+ day perishable, including fresh produce, and 7+day non-perishable supply of food in the kitchen. Refrigerator/freezer temperatures are recorded daily. Residents do not have access to the kitchen area where sharps are kept. There are (2) activity calendars posted for the month and activity staff will document resident's daily participation in each activity. Laundry machines were all working today, and scheduled monthly maintenance has been implemented. LPA reviewed (5) resident files. Files were organized and contained current physician's reports and care plans. Medications were reviewed for (1) resident. Orders match medications being given and electronic documentation is maintained. Pharmacy to provide Med-Techs with training on all aspects of medications in April 2025. *cont on 809C-2.. 809C-2.. The medication room and medication carts were organized and there are (2) Med-Techs on the 'am" and "pm" shifts. Each medication cart has a complete First Aid kit. LPA reviewed (5) staff files and found them to be organized and contain all the required documentation. Staff are in the process of completing the initial and/or continuing required training through an approved vendor. Documentation was on file. All staff is cleared and associated. All staff will be completing a two-year First Aid/CPR certification. Administrator RCFE #6069635740- exp 5/5/26. All required postings and non-audio cameras are in the common area. Discussed regulation changes made effective January 1, 2025. The Dementia Care Plan has been updated to include these changes. The Admission Agreement was reviewed also and observed to contain additional updated changes. Discussed Guardian roster and how to update staff information. LPA requested, current copy of liability insurance, LIC308 and updated staffing schedule (or LIC500)- due 4/7/25. There were no deficiencies observed during today's inspection. Exit interview. Copy of report left.