Routine inspection·January 22, 2025

On 01/22/24, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA met with direct care staff Rosemerry Manariangkuba and Rosita Sagala and explained the purpose of the visit. Direct care staff called and informed administrator Taty Sael to informed that CCLD was present in the facility. Administrator arrived at the facility approximately 20 minutes later and assisted with today’s visit. Administrator certificate # is 7034190740 and will expire on 06/02/25. The current census is 6 with 2 facility staff. This facility is a single story building licensed to six (6) non-ambulatory residents and approved for 3 hospice residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, residents’ bedrooms, residents’ bathrooms, laundry room, garage, and outside courtyards of the facility to ensure compliance with Title 22 regulations. It was observed the facility was free of odor and clean. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed the facility had sufficient seven day non-perishable food supplies and two day perishable food supplies at this time. Hot water temperature was measured at 114.6 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 11/26/24. The last fire drill was conducted on 10/08/24. LPA observed the facility has a has a public telephone in the kitchen. Facility thermostat observed at 72 degrees Fahrenheit. LPA observed toxins located in the garage and kept locked; however, LPA did observe a Lysol disinfectant spray in the hallway which was made accessible to residents in care at this time. LPA observed sharp knives kept locked and inaccessible to residents. LPA checked medication storage and found medication to be locked away and inaccessible to residents. Continued LIC 809-C LPA reviewed and 3 out of 6 residents medication administration record (MAR) along with residents medications and 2 out of 3 MAR was not complete. It was observed that 2 of the residents MARs did not have the correct physician's order and exact dosage. The first aid kit was checked, and it was complete. LPA requested resident and staff files for review. LPA Lee reviewed 5 out of 6 resident files and 1 out of 5 resident file was incomplete. Resident 1 (R1) did not have a complete LIC 625 Appraisal/Needs and Service. It was observed that the LIC 625 was blank with no signatures. LPA reviewed staff files and they were not complete. 1 out of 2 staff files were missing annual training's. LPA toured the courtyard and observed the emergency gate not in good repair. LPA 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. As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, LIC 9102 Technical Violation and Appeals rights were provided to the facility.